**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to provide appropriate supervision when a staff failed to use a gait belt to ensure each resident safety during a transfer for 1 of 3 residents reviewed (Resident #1) for safety. Resident #1 fell during the transfer which resulted in a left arm and wrist fracture. The facility reported a census of 109 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated moderate cognitive impairment. The MDS further indicated that the resident received partial/moderate assistance with transfers. The clinical census for Resident #1 revealed the following: a.7/21/25 admitted to the facility b.7/30/25 discharged from the facilityThe Care Plan initiated 7/22/25 indicated Resident #1 had a mobility deficit, utilized a front wheeled walker for transferring and required extensive assistance of 1 staff. A Progress Note dated 7/23/25 at 4:59 PM documented Resident #1 had been on the floor in the bathroom and according to the CNA the resident had been in front of the sink washing her hands and tripped backwards when she tried to turn with her walker. The CNA reported the resident dragged her down and she landed on the floor with the resident. An Incident Report (IR) dated 7/23/25 at 5:26 PM documented Resident #1 had a witnessed fall in the resident's bathroom after she had turned after washing her hands. The IR further documented a CNA had been with the resident but a gait belt had not been in place. An After Visit Summary dated 7/23/25 from a local emergency room (ER) revealed imaging tests were completed on Resident #1's left wrist and left elbow. The summary documented the reason for the visit was a fall, a diagnosis of a closed nondisplaced fracture of neck of left radius (forearm) had been determined and instructions to follow up with orthopedics for management of the fractures. The summary further documented the resident received an arm sling and left wrist splint. Review of the facility investigation of Resident #1's 7/23/25 fall revealed the resident had been sent to the ER immediately after the fall because she had been on a blood thinner. During an interview 9/16/25 at 12:25 PM, Staff A, Certified Nursing Assistant (CNA) revealed she had been in the bathroom with Resident #1 when the resident stepped back after washing her hands and then the resident tripped and fell back. Staff A stated she had been pulled down with the resident when she fell and landed next to the resident. Staff A stated she did not use a gait belt because she had looked around the room she did not see a gait belt. Staff A reported after the fall she went to get the nurse and the nurse was able to find a gait belt and she helped get the resident off the floor with a mechanical lift. Staff A acknowledged she was expected to use a gait belt when assisting residents with transfers. During an interview 9/16/25 at 12:35 PM, Staff B, Registered Nurse (RN) revealed the Staff A, CNA came and reported to her that Resident #1 was on the floor in the bathroom after she tripped after she had washed her hands. Staff B reported that Staff A had confessed to her that she had not been using a gait belt on Resident #1 prior to the fall. Review of the facility policy number 3.35 (IA) with the subject Gait Belts adopted 12/03, revealed all direct staff shall use a gait belt when transferring or ambulating residents for the protection of both staff and residents. All direct staff will have a gait belt available for use with transfers. No resident will be transferred or ambulated without the use of a gait belt, unless to do so is contraindicated and this would be identified on resident's plan of care. During an interview 9/17/25 at 9:40 AM, the Director of Nursing (DON) revealed it is an expectation staff utilize a gait belt per policy if a resident requires assistance with transfers.Review of the personnel file for Staff A, CNA revealed she completed the new employment checklist for a CNA on 9/13/24. The checklist included use of a gait belt. Review of in-service education revealed use of gait belt training had been completed on 9/30/24 and 7/16/25. Staff A, CNA signed that she had been present during both in-service training sessions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review the facility failed to implement and modify interventions, and provide safety to 1 of 3 residents reviewed for falls (Resident #67) who fell repeatedly at the facility and sustained two (2) fractures. The facility reported a census of 94 residents. Findings included: The Minimum Data Set (MDS) dated [DATE] for Resident #67 documented a Brief Interview of Mental Status (BIMS) score of 4 indicating he has severely impaired cognition. The MDS documented he does not walk, stand, or use the toilet and he is dependent on staff for toilet hygiene, and changing positions from lying to sitting and for transfers. The MDS also documented his primary diagnosis of fractures and other multiple traumas, Alzheimer's, and hip fracture. 1. Record review of a Progress Note dated 11/08/2023 at 4:14 PM for Resident #67 documented the kitchen chef walked down the hall and saw Resident #67 sitting on the floor in bathroom in front of his stool and notified staff. Resident #67 observed sitting with his back against the stool and facial grimacing with tears running down his cheeks. His right knee was bent out toward the wall. Resident #67 unable to straighten it due to pain, and he had an abrasion to the front of his knee. Resident #67 complaining of excruciating pain. Brief wet, changed. Vitals Signs taken and he was lifted to his bed using a mechanical lift. As needed, pain medication given and the resident sent to the local emergency room (ER). Record review of a Progress Note dated 11/08/2023 at 5:10 PM documented Resident #67 left by ambulance, he became briefly unresponsive when transferred, then again complained of severe pain to his knee. Record review of a Progress Note dated 11/09/2023 at 10:42 AM revealed the facility notified by Resident #67 daughter that he broke his right tibia (also known as the shin bone, is one of the two bones that make up the lower leg). Record review of a Progress Note dated 11/15/2023 at 1:30 PM Resident #67 returned to the facility and is non-weight bearing to his right side and a cast in place. Record review of a Progress Note dated 11/17/2023 at 3:26 PM by the Medical Practitioner revealed Resident #67 has a right tibia fracture and no surgical intervention at this time. 2. Record review of a Progress Note dated 1/08/2024 at 4:58 PM documented Resident #67 found sitting on the floor leaning on his wheelchair in the library with both legs out in front of him. Activity staff present and informed he slid to the floor with his left leg bent underneath him. Activity staff member tried to help him by slowing the fall and then sliding his left leg out from underneath him and to the front. During assessment when left leg was bent to assess Range of Motion (ROM) resident began to groan from pain and saying ow that hurts. Resident assisted back to his wheelchair using a mechanical lift with the nurse holding his left leg straight ahead per residents request. When placed in the wheelchair, the left leg appears to be rotated slightly outwards. Resident taken to his room and transferred into bed and transferred to the local ER. Record review of a Progress Note dated 1/16/2024 at 1:35 PM documented Resident #67 returned to the facility with a left femur fracture that had been surgically repaired. Record review of a Progress Note dated 1/17/2024 [Recorded as Late Entry on 01/24/2024 at 9:39) by Resident #67 Nurse Practitioner documented he was examined today and is on skilled services after hospitalization following another fall at the facility, this time with a left femur fracture. He has a new onset of decrease in strength, decrease in functional mobility, and reduced balance. The plan is to continue his comprehensive rehab program, strengthening and improving functional mobility. 3. Record review of a Progress Note dated 5/03/2024 at 11:00 AM revealed he went to the local urgent care and has a closed displaced fracture of the shaft of the fifth metacarpal bone (pinky finger) of his right hand. During an interview on 05/15/24 at 03:45 PM with the Assistant Administrator revealed the facility would have completed medical incident reports when the resident would have a fall but the facility is not able to provide that documentation at this time. She informed the provider was notified and determined the falls are not a major injury but does not have documentation to show this for all three of Resident #67 falls. During an interview on 5/15/24 at 5:11 PM with the facilities MDS Coordinator, she stated after continuous falls with Resident #67 it has been hard, because sometimes he knows what he is doing and sometimes he does not. One minute he is clear and the next he isn't. Record review of Resident #67 Care Plan with a start date of 10/25/2023 identified a Focus Area of Falls related to weakness, limited mobility and use of antidepressant medication. The Care Plan included the following interventions with start dates: a. Weight bearing as tolerated. 3/1/24 b. Activity staff either alert nursing when resident is done with an activity or take resident back to the common area near nursing. 1/30/24 c. Remind Resident #67 to call for assistance with cleaning up afternoon snacks.1/19/24 d. Total assist of 2 staff with transfers using manual stand lift. 11/15/23 e. Remind Resident #67 to call and wait for assistance with transfers, ambulation and to.11/10/23 f. Encourage Resident #67 to use side rails and handrails as needed.10/25/23 The Care Plan failed to identify appropriate interventions for resident cognitive status after each fall. Review of a Policy titled, Emergency Care Procedure last revised 4/3/2018 instructed the following: 1. Nurse in charge of the resident will evaluate the resident's condition. If help is needed and there is more than one nurse available, the nurse assigned to the resident will stay with the resident and will send a nurse's aide to go call the other nurse. The nurse's aide will also bring emergency equipment if needed. 2. Immediate Care of the Resident: A. Falls 1. Check the resident immediately for ability to move extremities. 2. Check residents ability to explain what happened; evaluate condition before fall 3. Check if, or with anyone who witnessed the accident. Determine, if possible, where, how and when. 4. Check for any apparent dislocation or possible fracture. If any signs of this are noted, stabilize the resident until the ambulance arrives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to provide a safe transfer while using a mechanical lift which resulted in an arm fracture, hematomas, and pain for 1 of 2 residents reviewed for mechanical lift transfers. (Resident#24) The facility reported a census of 81. Findings include: The Annual Minimum Data Set (MDS) assessment set dated 11/1/22 revealed the resident scored 14 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated cognitively intact. The MDS documented that the Resident required two staff for total dependence for transfers. The MDS revealed that the Resident required total dependence of staff for the following transfers; chair/bed-to-chair, toilet transfer, and car transfer. The MDS documented that the resident required extensive assistance with bed mobility with a two plus person physical assist. The MDS identified that the resident had the diagnoses which included generalized muscle weakness, unsteadiness on feet, morbid (severe) obesity due to excess calories, and a body mass index between 45-49.9. The Care Plan dated 10/26/21 with a problem of Falls revealed Resident #24 was at risk for falls related to pain, weakness, Atrial Fibrillation, and use of anti-depressants. Interventions dated 7/5/22 indicated the resident needed a total assist of 2 staff with transfers using a full mechanical lift. A Search Vitals Results dated 6/28/22 to 2/02/23 documented the following weights for Resident#24; 12/5/22 309.2 pounds and on 1/4/23 294 pounds The Fall Risk assessment dated [DATE] identified a score of 13 which indicated a Moderate Fall Risk for Resident #24. The Event Report dated 12/26/22, stated Resident #24 fell from the mechanical lift sling when transferred with the Hoyer lift. The resident slipped out of the Hoyer sling resulting in left forearm pain. The resident sent to the Emergency Department and evaluated. The Emergency Department (ED) Provider Aware Notes on 12/26/22 at 12:47 PM stated resident was transferred via Hoyer lift on 12/26/22 and there was some sort of issue and the resident fell from the lift. The Provider Note revealed the resident stated she landed on her left side and buttocks and complained of moderate pain in her left wrist along the ulnar process that was constant and non-radiating. The Progress Notes dated 12/26/22 at 1:22 PM, revealed CNA (Certified Nurse Aide) reported to the nurse Resident #24 slipped from the Hoyer sling during the mechanical lift transfer. The resident found laying on her back and the left side parallel to the bed with the Hoyer sling hooked up to the Hoyer lift. Resident #24 confirmed she had slipped out of the sling while transferring to her wheelchair and landed on her buttocks and the left side. Resident #24 complained of a 6 out of 10 pain to her left forearm and redness and swelling observed by the nurse. Resident refused initially to be transported to the hospital but eventually changed her mind and sent to the hospital. The Radiology report dated, 12/26/22 at 1:23 PM, showed findings of severe degenerative changes of the first and second carpal-metacarpal joints. The findings also included an old distal left ulnar fracture. The lateral view showed a fracture of the radius, ulna, or both. The report recommended dedicated left forearm radiographs. The Emergency Department (ED) Discharge Instructions dated, 12/26/22 stated the ED clinical impression was scapholunate (wrist ligament) instability with acute wrist pain. Additional information included that due to the arthritis and osteopenia it was difficult to determine if there was a fracture present. There was an old injury to the wrist also visible, recommend a removable splint at this time. The Progress Notes, 12/26/22 at 3:20 PM showed Resident #24 returned from the Emergency Department (ED) and an X-Ray had been performed on her left arm and the ED was unable to determine if Resident #24 left arm was fractured due to arthritis. The Physical Therapy Encounter Notes dated 12/27/22 at 4:38 PM revealed the resident presented to therapy at baseline functional mobility and level of assistance. The resident reported increased left hip pain since she had fallen out of the Hoyer sling and landed on her hip. Therapy services for pain management and re-evaluate and reestablish HEP (Home Exercise Program). The Nurse Practitioner Progress Notes dated, 12/29/22 at 10:25 AM revealed Resident #24 had continued pain in her lower back and hip since the fall. The imaging was negative for any fractures/dislocations. Hydrocodone prescribed for pain as needed for 5 days for pain management. The Progress Notes dated, 12/29/22 at 12:00 PM showed resident's daughter was notified her mother was being sent to the hospital due to increased pain. The Progress Notes dated 12/29/22 at 12:20 PM revealed the resident was sent to the hospital and took a blue sling with her to the hospital. The ED Provider Aware Notes dated 12/29/22 at 1:32 PM revealed the resident was sent to the emergency room due to continued worsened hip pain and wanted further imaging. The Computerized Tomography Scan (CT) without contrast of the pelvis dated 12/29/22 at 2:30 PM revealed a 11.7 x 0.9 x 11.9 centimeters (cm) right rectus sheath hematoma. The scan also identified an additional high density collection measured approximately 9.3 x 5.1 x 6.7 cm superior to the bladder. A CT with contrast was performed on 12/29/22 at 5:14 PM, to rule out intra-abdominal bleeding. The results found the right rectus sheath hematoma in better effect as well as the adjacent area of hemorrhage. These encompass a single large hematoma which extended from the right rectus muscle into the central to the right lateral aspect of the space of Retzius, retropubic extraperitioneal space. The acute hematoma measured approximately 20 cm in craniocaudal extent, 14 cm in maximum width, and 7 cm in anteroposterior (AP) dimension. The Progress Notes dated 12/31/22 at 8:19 AM showed the resident had pain that radiated from her arm to her chest and was sent by ambulance to the hospital. Resident told the staff it hurt to breathe, move or doing anything period. Resident cried when head of bed (HOB) was raised. The ED Provider Aware Note dated 12/31/22 at 8:37 AM, revealed resident had a X-ray of the left wrist with concern of a scapholunate ligament injury and was in a thumb spica splint. It also appeared that there was a possible diaphysis fracture of the radius and dedicated forearm X-rays were recommended but didn't appear to be completed. The resident's pain was constant, aching, and mild in severity and worsened with palpation. The resident was then placed in a long ulnar gutter splint and discussed ongoing supportive care, pain control, and that the fracture was non-operative. Resident was on Oxycodone for pain. The Radiology Report dated 12/31/22 at 9:27 AM, showed a nondisplaced fracture of the diaphysis of the distal left ulna. It was noted the fracture was present on the prior exam described in the report. The Progress Notes dated 12/31/22 at 10:48 AM, revealed the nurse received report from the hospital that showed a non-displaced ulnar fracture was found. The Progress Notes dated 1/1/23 at 12:37 AM, indicated the resident had an immobilizer applied to the left wrist and the fracture should heal in 4 to 6 weeks. The CT scan of the abdomen and pelvis dated 1/2/23 10:44 AM showed the rectus sheath hematoma may had slightly decreased in size and the mass effect upon urinary bladder was also stable. The Discharge summary dated [DATE] at 9:33 AM, stated the resident was seen on 12/26/22 after a fall and had a nondisplaced left distal ulnar fracture. The Discharge summary stated the resident seen on 12/29/22 with hip pain after a fall, found to have a rectus sheath hematoma and a hematoma to the posterior bladder area. The Progress Notes dated 1/4/23 at 6:39 PM, revealed the resident returned to the facility and a splint and ace wrap were applied to the left wrist. Resident complained of aching of the wrist and burning of the hematoma behind the bladder. The Nurse Practitioner Progress Notes dated 1/5/23 at 10:27 AM, showed resident had a cast to the left wrist and stated further imaging showed a fracture. The Physician Progress Notes on 1/16/23, revealed a non-displaced mildly comminuted left distal fracture ulnar metaphyseal fracture. A short arm cast with fiberglass rolls applied in the physician's office. During observation on 1/30/23 at 11:18 AM, revealed Resident's #24 left wrist in a cast elevated on a pillow. During an interview on 1/30/23 at 11:18 AM, Resident #24 stated she fell out of the Hoyer lift during a transfer on 12/26/22. She stated she had a bruise on her bladder that they gave her pain medication for it. Resident #24 stated she had slid out of the Hoyer and hit her head, arm, and landed on her bottom. During an interview on 1/31/23 at 8:23 AM, queried Staff G, CNA (Certified Nurse Aide) about how do they know what size of Hoyer sling size to use and Staff G stated it goes by the weight of the resident. Staff G stated it goes by the binding (color of outer edge) of the sling, not the color of the sling. Staff G stated red is the smallest, then yellow, green, and blue. The Medical Sling recommended Sizing Chart provided and also observed in the utility room of the facility documented the following: a. Small 75 to 124 pounds (Red) Maximum 600 pounds. b. Medium 125-174 pounds (Yellow) Maximum 600 pounds. c. Large 175-249 pounds (Green) Maximum 600 pounds. d. Extra Large 250-399 pounds (Blue) Maximum 600 pounds. e. Extra, extra Large 400-750 pounds (Orange) Maximum 1000 pounds. Documentation on 12/26/22 had revealed the resident weighed 303.3 pounds which showed the recommended sling would be blue. During an interview on 2/1/23 at 11:20 AM, queried Staff D, LPN (Licensed Practical Nurse) about the Hoyer lift incident with Resident #24. Staff D stated she was at the nurse's station when a CNA came and got her. Staff D stated Resident #24 did not have pain except for her back and she had chronic back pain. Staff D stated Resident #24 didn't want to go to the hospital at first so they put her back in the bed. Asked Staff D what size the Hoyer pad was and Staff D responded she did not do a lot of Hoyer transfers so she would have to look it up. Staff D stated the facility ordered two special slings for Resident #24 that night or the next day. Queried Staff D how Resident #24 fell and Staff D stated she came straight down out of it and Resident #24 had scrapes on her legs where the leg straps had rubbed against her. Queried how did the CNAs know what sling to use and Staff D stated if the CNA question the size, they would ask a nurse to look it up. During an interview on 2/1/23 at 12:42 PM, queried Staff G about the Hoyer lift incident with Resident #24. Staff G stated they used the Hoyer sling the same way they had always done it. Staff G stated the slings legs were criss-crossed like they were supposed to be. The straps were blue on the bottom, green in the middle, and yellow on the top (noted to be the colors of the loops on the sling to connect loops to Hoyer lift). Staff G stated they were moving Resident #24 towards the wheelchair and her feet started to go up and the Resident #24 hit her arm and then her bottom fell out of the sling. Staff G stated her body was in the sling like it was supposed to be and the resident had marks on her legs where the leg straps were criss-crossed. Staff G stated nothing was broke on the Hoyer and the straps were still intact and secured on the lift. Queried Staff G what size of sling Resident #24 used and Staff G stated blue. Asked Staff G what color of sling they used on the day of the incident and Staff G stated they used a green sling because they could not find a blue sling to use and there was already a green sling in the resident's room. Staff G stated the resident was not much off from the green because she fluctuated in weight. Staff G stated she had never used a green sling with the resident but other staff had before. Queried Staff G what sling they used to put the resident back in bed on 12/26/22 and she stated they found a blue sling hanging up in laundry that had dried. Staff G stated the Administrator didn't want the other sling used until it was inspected. Staff G stated new slings were ordered and they are bariatric slings and they are used for Resident #24. Staff G stated she was not aware when the new slings were ordered. Staff G stated the facility purchased new Hoyer lifts last year and she thought they received 4 new slings with them. During an interview on 2/2/23 at 10:18 AM, Resident #24 stated they had left her in her chair too long yesterday evening and she was too sore to get out of bed today. When asked how long she had been in the chair Resident #24 responded she was not sure, she didn't have a watch. During an observation on 2/2/23 at 10:20 AM, revealed Resident #24 lying in bed with her left arm casted elevated on a pillow. A gray sling with a blue binding was laid on the chair next to her bed. Staff H came into the room and asked Resident #24 if she was going to get up and Resident #24 stated no, she hurt to much. Staff H asked her if she wanted her to speak to the nurse to see if it was time for her pain pill and Resident #24 said no, the nurse knew when it would be time. During an interview on 2/2/23 at 11:01 AM, queried Staff H, CNA about the Hoyer incident with Resident #24. Staff H stated they did not have the right size sling because they could not find the blue sling. Staff H stated they got the resident dressed and in the sling and lifted her off the bed and everything was fine. Staff H stated when they moved her, the resident's bottom fell out of the sling. Staff H stated they double checked the straps and they were correct and the legs were criss-crossed and you could tell because the resident had marks on her legs from the leg straps. Asked Staff H what sling size they were to use on Resident #24 and she stated we are supposed to use a blue sling but we used a green sling. Staff H stated she believed the green one was smaller. Asked Staff H how did she know which sling to use and Staff H responded they had a chart in the utility room room that showed what sling to use with the resident's weight. Staff H stated Resident #24 was on the border between the slings. Staff H stated if they question a resident's weight they went and asked the nurse what the resident's weight was and went to the chart for clarification. Queried Staff H if she used the slings in the resident's room and Staff H responded no we usually have what we need on the floor, and that day they used green because they did not have blue available. Staff H stated Resident #24 needed a bariatric sling not because of her weight but because of her width. Staff H stated they had asked prior to the incident for bariatric slings for Resident #24 but it took this incident for them to order them. Staff H stated the bariatric slings are gray ones and they are only used for Resident #24. During an interview on 2/2/23 at 12:04 PM, queried Staff H, CNA if the facility gave an education on the incident. Staff H stated they told them they had been doing this long enough they should know what to do. She stated she had been telling them Resident #24 needed a bariatric sling since November and she was told the resident was in the weight range of the slings they had. Staff H stated the facility printed off something and put it at the nurse's station and they were told to read and sign it. Staff H stated the Administrator and the shift coordinator talked to them that day about the incident but they did not do an inservice for the incident. During an interview on 2/2/23 at 1:14 PM, queried the Administrator about the Hoyer incident with Resident #24, and she stated she came in at approximately 1:30 PM and the resident did not initially want to go to the hospital but the nurse convinced her to go. The Administrator stated she had Staff H and Staff G do a return demonstration with her in the sling and they did everything correctly. She stated the CNAs stated they didn't know what happened and it might have been from her shape she fell down. The Administrator stated she inspected the sling herself and there were no tears, rips, or anything wrong with the sling they used. She stated the CNAs did it exactly to policy and when the incident was investigated nothing was found to be in error. Queried the Administrator on the expectations of staff when performing Hoyer lifts and she stated to follow policy and procedure of which they did. Asked the Administrator what should staff do if the right size sling is not available and she responded she was not aware of that ever happening and the right size was always available because they had ample supply. Queried the Administrator about how staff know what size sling to utilize and she responded they have a manual they go over and a chart is in the utility room for the color to match the weight. Queried the Administrator if any interventions were put in place for the resident after the incident and she stated the resident was sent to ER (Emergency Room) and she had spoken to her support service staff and after discussion ordered a different sling (a long seat sling) for the resident. She stated they ordered a different sling from a different manufacturer with the correct size. She stated the new sling was compatible with the Hoyer lift they used. She stated the manufacturer of the Hoyer lifts they currently used stated the facility's previous slings they used were compatible with the new Hoyer lift. Asked what sling was used with the Hoyer incident and the Administrator responded they used the previous style sling with the new lift but it was approved. Queried the Administrator if any education was done with the staff after the incident and she stated yes they did an in service on that day. During an interview on 2/2/23 at 2:58 PM, queried the Administrator on what color sling was used during Resident #24 incident, and she responded it was blue. Asked the Administrator the color of the sling used for the return demonstration and she responded blue. Asked if she used a different sling than Resident #24 and said no, they were both blue and they were the appropriate size. When notified the staff had said the sling they used was green, the Administrator responded that maybe they were green, she would have to check because she might be thinking of the color of the pad and not the cord (binding). She stated there was an overlap in sizes and stated she would provide a chart. When asked if the chart was the same for all, the slings and the Administrator stated yes. During an interview on 2/2/23 at 3:18 PM, the Administrator stated she had initially forgot but Resident #24 was in the green sling. She stated she had spoken to the CNAs and pointed to the sling sizing chart and stated these are the recommended weights for the slings but the maximum weight was 600 pounds. She stated they didn't know how she slid out of the sling because you could go down a size but not go up in size. When asked if the older slings were used, the Administrator stated yes. When asked the Administrator what sling she used for the return demonstration, she stated it must have been the blue but still the maximum was 600 pounds. She stated the resident should have not fell out because the hole would have been smaller. The Administrator then stated the resident could have used the blue or green with both types of slings. Per the Hoyer full back sling manual for the type of Hoyer lift, it was documented, warning .Hoyer slings and lifters are not designed to be interchangeable with other manufacturer's products. Using other manufacturers on Hoyer products is potentially unsafe and can result in serious injury to patient or caregiver. The Hoyer Instructions Manual also documented the warning . For the safety of the patient and carer, before use of a sling a full assessment must be conducted that ensured the correct sling choice, method of position in sling, and the procedure for transfers had been determined for the patient. The Sling manual documented the following warnings: a. Select a sling that was sized appropriately for the resident. Slings that are too small may force a resident to fall out or exert unsafe pressure on the pelvic area. b. Sling failure or improper sling sizing or improper attachment may cause serious injury. Comply with instructions, inspections, and warnings. The Facility Policy Lifting Devices dated 2/12 stated all staff would be instructed on the proper use of the lifts, and each staff person would do a return demonstration in the proper techniques of use of the lifts.