**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to implement the comprehensive person-centered care plan for one (1) of twenty-eight (28) sampled residents (Resident #61). Resident #61's Comprehensive Care Plan, revised 01/05/2024, revealed an intervention to utilize the mechanical lift with two (2) staff members for transfers. However, on 02/01/2024, Certified Nursing Assistant (CNA) #7 and CNA #14, transferred Resident #61 from the bed to the wheelchair without using a mechanical lift (device used to transfer residents who require support for mobility beyond the manual support provided by caregivers alone). Resident #61 sustained a laceration to the left lateral calf which required a transfer to the hospital emergency room (ER) for placement of three (3) skin clips (medical metallic device used to close open wounds). Additionally, on 02/21/2024, CNA #13 failed to implement Resident #61's Comprehensive Care Plan related to the intervention to utilize the mechanical lift with two (2) staff members for transfers. CNA #13 transferred Resident #61 without the assistance of another staff member and without using the mechanical lift and caused a skin tear to the resident's left lower leg. Refer to F689 The findings include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, undated, revealed a comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs and is developed and implemented for each resident. The policy further stated the care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The Interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative develops and implements a comprehensive, patient-centered care plan for each resident. Review of the facility policy titled Using the Care Plan, undated, revealed the care plan shall be used in developing the resident's daily care routine and would be available to staff personnel who had the responsibility for providing care or services to the resident. The comprehensive, person-centered care plan would, among other things, describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Identified problem areas would be incorporated into the care plan and assessments of residents were ongoing. Care plans were revised as information about the residents and resident's conditions changed. Review of Resident #61's medical record revealed the facility admitted the resident on 12/18/2019 with diagnoses including dementia in other diseases classified elsewhere, severe with other behavioral disturbance, contractures to left and right Knee, and hypertensive heart disease without heart failure. Review of Resident #61's Annual Minimum Data Set (MDS) Assessment, dated 11/11/2023, revealed the facility assessed the resident as being unable to interview and as rarely or never understood. Further review revealed the facility assessed Resident #61 as totally dependent on staff for transfers. Review of Resident #61's Comprehensive Care Plan, dated 12/18/2019, revised 01/05/2024, revealed a focus problem for Activities of Daily Living (ADLs) self-care performance deficit related to dementia, late-stage Alzheimer's, and contractures. The care plan goal stated the resident would be neat, clean, and well groomed and would maintain current level of functioning through next review. Interventions included the assistance of two (2) staff with use of a mechanical lift for transfers using a Yellow (Liko) or [NAME] (Proactive) sling. This intervention was initiated on 01/05/2024. Resident #61's Mechanical Lift Evaluation, dated 01/05/2024, revealed the resident was assessed for the correct size of sling to use, the sling size information had been care planned, the care plan was updated to reflect change in transfer ability, and staff was educated on change in transfer and correct sling to use. Review of Resident #61's Point Click Care (PCC, a software program used for charting) record, under the [NAME] (nurse aide care plan) section, revealed transfers required total care with two (2) staff assist with a mechanical lift with use of a yellow Liko or a [NAME] Proactive sling for transfer to the wheelchair. This intervention was tagged to the [NAME] from Resident #61's care plan intervention by the MDS Coordinator on 01/05/2024. Review of Resident #61's Progress Note, dated 02/01/2024 at 11:00 PM, entered by Licensed Practical Nurse (LPN)/ Unit Coordinator (UC) #2, revealed she was notified by the medication nurse, LPN #4, the resident sustained a skin tear to the Left lower extremity. Per the Note, the nurse assessed and documented the wound as a laceration about four to five (4-5) inches wide and deep with bleeding noted. The area was cleansed and the wound edges were approximated (the edges of the wound fit together) and steri-strips (small adhesive strips of wound material) were applied, and covered with a dry dressing. Additional review of the Note, revealed the Nurse Practitioner (NP) was notified and advised LPN/UC #2 she would be in to see Resident #61 before providing new orders. Review of Resident #61's Progress Note, dated 02/01/2024 at 11:56 PM, entered by LPN/UC #2, revealed at 5:05 PM, the CNA notified the nurse the resident received a skin tear during transfer. The nurse immediately cleansed the area and applied a bandage. The Nurse Practitioner and family were notified. Review of Resident #61's Progress Note, dated 02/02/2024 at 3:35 AM, revealed the NP assessed the laceration with LPN/UC #2. Further review revealed the NP gave the order to send Resident #61 to the Emergency Room. Resident #61's Discharge Summary from the local hospital, dated 02/02/2024, at 3:50 AM, revealed the resident sustained a five (5) centimeter (cm) laceration with controlled bleeding and superficial avulsion (the action of pulling or tearing away) located in the lateral aspect of mid leg, described as U-shaped with convex toward shin. Three (3) skin clips were used to close the laceration. Additional review revealed Resident #61 received a Tetanus immunization, and was deemed stable and discharged back to the facility. In an interview with CNA #7, on 03/08/2024 at 3:22 PM, she stated she recalled she (CNA #7) and CNA #14 assisted Resident #61 from the bed to the wheelchair to get the resident ready for supper without the use of a Hoyer lift (mechanical lift). CNA #7 stated after the transfer it was noted the resident's left leg was bleeding. CNA #7 recalled Resident #61's feet did touch the floor with the transfer, but stated she did not know if the resident's leg hit the chair because the resident's leg was bleeding after the transfer. CNA #7 stated Resident #61 did not make any indication that he/she she had sustained an injury and seeing the blood was what indicated an injury. CNA #7 was questioned if she reviewed the Care plan or [NAME] to ensure proper transfer technique prior to this transfer and CNA #7 stated she did not remember checking it, but did recall asking someone how Resident #61 was to be transferred. She could not remember who she had asked. CNA #7 further stated she was unaware Resident #61 required a Hoyer lift for transfer at the time of the transfer on 02/01/2024. During a telephone interview with CNA #14, on 03/08/2024 at 3:31 PM, she stated she no longer worked at the facility. She further stated she (CNA #14) and CNA #7 transferred Resident #61 from the bed to the wheelchair on 02/01/2024 without the use of a Hoyer lift and then they noted the resident's leg was bleeding. CNA #14 stated she recalled Resident #61 required two (2) staff to assist with transfer, but she did not know if the resident required a mechanical lift for transfers. CNA #14 stated she was in orientation on 02/01/2024, at the time of Resident #61's transfer, it was her second or third day on the job, and she did not recall checking the Care plan or [NAME] prior to this transfer. During an interview with LPN #4, she stated she recalled the incident on 02/01/2024 related to Resident #61 sustaining a skin tear. She further stated when the CNAs were transferring the resident from the bed to the wheelchair, Resident #61 sustained a skin tear which was located on the resident's left lower extremity, below the knee on the lateral area of the leg and she wrote it up as an incident. LPN#4 could not recall if it was a large skin tear, but stated she dressed the wound. In further interview, LPN #4 stated she could not recall Resident #61's transfer status at the time of the incident because she floated throughout the facility and was not very familiar with the resident. However, she stated the CNAs were expected to check the Care plan or [NAME] for information related to providing care for residents. She further stated she left at 11:00 PM that night and LPN/UC#2 relieved her and she gave LPN/UC#2 report. In an interview with LPN/UC #2, on 03/07/2024 at 4:41 PM, she stated on 02/01/2024, she worked from 7:00 PM-11:00 PM as House Supervisor and after 11:00 PM she worked as medication nurse. Further, she stated during her shift LPN #4 asked her to check on a resident who had a skin tear. She stated she assessed Resident #61 and notified the Nurse Practitioner who gave orders to send the resident to the Hospital emergency room (ER). In further interview, LPN/UC #2 stated the CNAs were to review the Care plan and [NAME] prior to transferring a resident to ensure they were using the correct transfer technique. LPN/UC #2 stated she was unaware of how Resident #61 was transferred on 02/01/2024 when the resident sustained the skin tear. In an interview with Director of Nursing (DON), on 03/07/2024 at 5:09 PM, she stated she was notified upon arrival to the facility on [DATE], Resident #61 had sustained a laceration. The DON stated she called and obtained a statement from CNA #7 who told her she did not use the mechanical lift because she asked someone else how the resident was transferred and was told Resident #61 was transferred with the assist of two (2) staff. In continued interview with the DON, she stated CNA #7 received Teachable Moment education regarding using the Care Plan and [NAME] prior to providing resident care. Additionally, she stated she was not able to reach CNA #14 for a statement as the CNA did not return to work after 02/01/2024. 2. Further review of Resident #61's medical record revealed a Nurse Progress Note, dated 02/21/2024 at 5:00 AM, entered by LPN #5, which revealed this morning upon getting the resident up, as CNA was transferring the resident from the bed to the wheelchair, the resident's left lower leg was bumped up against the wheelchair causing a skin tear. In an interview with LPN #5, on 03/07/2024 at 8:37 PM, she stated on 02/21/2024, CNA #13 informed her Resident #61 received a skin tear to the left lower leg. She stated the CNA informed her he saw blood on the resident's pants after assisting the resident with a transfer independently and without a mechanical lift. LPN #5 stated the new skin tear was next to the previous skin tear on the Left lower extremity. LPN #5 stated she then instructed CNA #13 to never attempt to lift a resident who required a mechanical lift for transfer and to always check the Care Plan or [NAME] prior to transferring a resident to ensure proper transfer technique. A phone interview with CNA #13 was attempted on 03/07/2024 at 9:01 AM and 03/08/2024 at 10:02 AM and messages were left; however there was no return phone call. CNA #13 no longer worked at the facility. During an interview with the DON, on 03/08/2024 at 6:47 PM, she stated it was her expectation that all nursing staff utilized the Care plan and [NAME] as a reference related to transfer technique. The DON stated the facility would continue to fully educate regarding following the care plan for all residents. In an interview with the Administrator, on 03/08/2024 at 7:09 PM, she stated it was her expectation for staff to discuss the residents in the care plan meetings as a team, follow policy, and procedure related to developing and revising care plans, and provide care according to the care plan for the safety of the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for two (2) of twenty-eight (28) sampled residents (Resident #61 and Resident #74). 1. On 02/01/2024, Certified Nursing Assistant (CNA) #7 and CNA #14, transferred Resident #61 from the bed to the wheelchair without using a Hoyer mechanical lift (device used to transfer residents who require support for mobility beyond the manual support provided by caregivers alone). Resident #61 sustained a laceration to the left lateral calf and required transfer to the hospital emergency room (ER) for placement of three (3) skin clips (medical metallic device used to close open wounds). Subsequently, on 02/21/2024, CNA #13 transferred Resident #61 from the bed to the wheelchair, without the assistance of another staff member and without using the mechanical lift and caused a skin tear to the resident's left lower leg. 2. On 01/10/2024, CNA #2 transferred Resident #74 from the bed to the wheelchair using a Hoyer mechanical lift. After the transfer, it was observed by staff, the Hoyer lift pad was improper fitting in size, resulting in skin-shear injury to the resident's left gluteal fold. (The Hoyer lift requires the use of a lift pad that acts a harness under and surrounding the resident for transfer support, stability, and safety). Refer to F656 The findings include: Review of the facility provided policy titled, Using a Mechanical Lifting Machine, dated 2001, revised December 2023, revealed the purpose of the procedure is to establish the general principles of safe lifting using the mechanical lifting device. It is not a substitute for manufacturer's training or instructions. The document includes provisions for general guidelines and procedural steps, including placing the sling under the resident, and visually checking the size to ensure it is not too large or too small. Continued review revealed at least two (2) staff were needed to safely move a resident with a mechanical lift. Review of the facility's policy titled, Safe Lifting and Movement of Residents, dated 12/2023, revealed in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. The policy stated staff must follow manufacturer's guidelines to operate a (Hoyer) mechanical lift. The document stated staff responsible for direct resident care will be trained in the use of manual and mechanical lifting devices. 1. a) Review of Resident #61's Face Sheet revealed the facility admitted the resident on 12/18/2019, with diagnoses to include dementia with other behavioral disturbance, contractures to left and right knee, and hypertensive heart disease without heart failure. Review of Resident #61's Annual Minimum Data Set (MDS) Assessment, dated 11/11/2023, revealed the facility assessed the resident as unable to interview. Continued review of the MDS Assessment, revealed the facility assessed the resident as totally dependent on staff for transfers. Review of Resident #61's Comprehensive Care Plan, dated 12/18/2019, revised 01/05/2024, revealed a focus of Activities of Daily Living (ADLs) self-care performance deficit related to dementia, late-stage Alzheimer's, and contractures. The goal stated the resident will be neat, clean, and well groomed and will maintain current level of functioning through the next review. Interventions for transfers revealed the resident required total care of two (2) staff assist with a mechanical lift using a Yellow Liko or [NAME] Proactive lift pad. The intervention was added by the Minimum Data Set (MDS) Coordinator on 01/05/2024. Review of the Mechanical Lift Evaluation, dated 01/05/2024, revealed Resident #61 was assessed for the correct size of sling to use. Further review of the Evaluation, revealed the care plan was updated to reflect change in transfer ability, and staff were educated on change in transfer and correct sling to use. Review of Resident #61's Point Click Care (PCC, a software program used for charting) record, under the [NAME] (nurse aide care plan) section, revealed transfers required total care with two (2) staff assist with a mechanical lift and the use of a yellow Liko or a [NAME] Proactive sling for transfer to the wheelchair. This intervention was tagged to the [NAME] from Resident #61's care plan intervention added by the MDS Coordinator on 01/05/2024. Review of Resident #61's Progress Note, dated 02/01/2024 at 11:00 PM, entered by Licensed Practical Nurse (LPN)/ Unit Coordinator (UC) #2, revealed she was notified by the medication nurse, LPN #4, about a skin tear to Resident #61's Left lower extremity. LPN/UC #2 assessed Resident #61's left lower extremity and documented the wound as a laceration about four to five (4-5) inches wide and deep with bleeding noted. LPN/UC #2 documented the area was cleansed and the wound edges were approximated (the edges of the wound fit together) and steri-strips (small adhesive strips of wound material) were applied, and covered with a dry dressing. Further review of the Note, revealed the Nurse Practitioner (NP) was notified and advised LPN/UC #2 she would be in the see Resident #61 before providing new orders. Review of Resident #61's Progress Note, dated 02/01/2024 at 11:56 PM, entered by LPN/UC #2, revealed at 5:05 PM, the CNA notified the nurse that the resident received a skin tear during transfer. The nurse immediately cleansed the area and applied a bandage. The Nurse Practitioner and family were notified. Review of Resident #61's Progress Note, dated 02/02/2024 at 3:35 AM, revealed the NP went to Resident #61's room to assess the laceration with LPN/UC #2. The NP gave the order to send Resident #61 to the Emergency Room. Interview with the Nurse Practitioner (NP), on 03/07/2024 at 10:35 AM, regarding Resident #61's injury, confirmed she was notified of the skin injury and advised the caller that she would be in to see Resident #61 the morning of 02/02/2024. The NP confirmed she came to the facility on [DATE] at 3:35 AM to assess Resident #61's wound. However, she stated she did not actually view the wound when she came to the facility. Further, she stated since she trusted the nursing judgement of LPN/UC#2, she went ahead and gave orders to send the resident to the ER. Review of Resident #61's Discharge Summary from the local hospital, dated 02/02/2024, at 3:50 AM, revealed the resident sustained a five (5) centimeter (cm) laceration with controlled bleeding and superficial avulsion (the action of pulling or tearing away) located in the lateral aspect of the mid leg, described as U-shaped with convex toward shin. Three skin clips were used to close the laceration. Further review revealed Resident #61 received a Tetanus immunization, and was deemed stable and discharged back to the facility. During an interview with CNA #7, on 03/08/2024 at 3:22 PM, she stated she recalled that she (CNA #7) and CNA #14 were assisting Resident #61 from the bed to the wheelchair to get the resident ready for supper without the use of a mechanical lift. CNA #7 stated Resident #61's feet touched the floor with the transfer, and after the transfer it was noted the resident's left leg was bleeding. She stated she did not know if the resident's left leg hit the chair with the transfer possibly causing the injury. CNA #7 was asked if she reviewed the [NAME] to ensure proper transfer technique prior to this transfer and CNA #7 stated she did not remember checking it, but did recall asking someone how Resident #61 was to be transferred. She could not recall who she had asked. CNA #7 further stated she was unaware CNA #7 required a mechanical lift for transfer at the time. Further, CNA #7 stated Resident #61 did not indicate he/she had sustained an injury during the transfer, but she (CNA #7) noted the resident's leg was bleeding after the transfer. Review of training revealed CNA #7 completed a Relias training with a certificate for Transfers: Mechanical Lift. However, the facility did not provide training information to indicate CNA #7 was checked off on using the lift with return demonstration. In a telephone interview with CNA #14, on 03/08/2024 at 3:31 PM, she stated she could not recall the last day she worked at the facility. During continued interview with CNA #14, she stated, she (CNA #14) and CNA #7 transferred Resident #61 from the bed to the wheelchair on 02/01/2024 without the use of a mechanical lift and then they saw the resident's leg was bleeding. CNA #14 recalled Resident #61 required two (2) persons to assist with transfer, but she did not know if the resident required a mechanical lift for transfers. CNA #14 stated she was in orientation on 02/01/2024, at the time of Resident #61's transfer and it was her second or third day on the job. Review of the Employee Timecard Report for CNA #14, revealed during the recording period of January 28, 2024 through February 03, 2024, CNA #14 worked on 01/29/2024, 01/31/2024, and 02/01/2024. There were no additional hours worked after 6:57 PM on 02/01/2024. In an interview with LPN #4, she stated she recalled the incident on 02/01/2024. She stated when the CNAs were transferring Resident #61 from the bed to the wheelchair, Resident #61 sustained a skin tear. She stated she dressed the wound which was located on the resident's left lower extremity, below the knee on the lateral area of the leg and wrote it up as an incident. In continued interview LPN #4, she stated she could not recall if the resident had a large skin tear nor the resident's transfer status at the time of the incident because she floated throughout the facility and was not familiar with the resident. She stated she left at 11:00 PM that night and LPN/UC#2 relieved her. During interview with LPN/UC #2 on 03/07/2024 at 4:41 PM, she stated on 02/01/2024, she recalled working from 7:00 PM-11:00 PM as House Supervisor and after 11:00 PM, she worked as the medication nurse. She stated during her shift on that date, another LPN asked her to assess Resident #61 related to a skin tear. Further, she stated she then notified the Nurse Practitioner who gave orders to send the resident to the Hospital emergency room (ER). In continued interview, LPN/UC #2 stated she was unaware of how Resident #61 was transferred on 02/01/2024 when the resident sustained the skin tear. During an interview with the Director of Nursing (DON), on 03/07/2024 at 5:09 PM, she stated she was notified upon arrival to the facility on [DATE], Resident #61 had sustained a laceration overnight. The DON further stated she called and obtained a statement from CNA #7 who told her she did not use the mechanical lift because she asked someone else how the resident was transferred and was told Resident #61 was transferred with the assist of two (2) staff. In further interview with the DON, she stated CNA #7 received a Teachable Moment education regarding using the [NAME]/Care plan prior to providing resident care. Additionally, the DON stated she was not able to reach CNA #14 for a statement as the CNA did not return to work after 02/01/2024. 1 b) Review of the Nurse Progress Note, dated 02/21/2024 at 5:00 AM, entered by LPN #5, revealed this morning upon getting the resident up, as CNA was transferring resident from the bed to the wheelchair, the resident's left lower leg was bumped up against the wheelchair causing a skin tear. In an interview with LPN #5, on 03/07/2024 at 8:37 PM, she stated on 02/21/2024, CNA #13 informed her there was blood on Resident #61's pants after assisting him/her with a transfer. LPN #5 stated she assessed the resident to have a skin tear to the left lower leg. Further, LPN #5 stated the new skin tear was next to the previous skin tear which was sustained on 02/01/2024 to the Left lower extremity. LPN #5 stated she cleansed the wound, and applied a bandage. LPN #5 further stated she completed change of condition documentation in the medical record and made the required notification. In continued interview, LPN #5 stated CNA #13 informed her he had transferred the resident himself independently and without a Hoyer lift. LPN #5 stated she then instructed CNA #13 to never attempt to lift a resident who required a Hoyer lift for transfer. A phone interview with CNA #13 was attempted on 03/07/2024 at 9:01 AM and 03/08/2024 at 10:02 AM and messages were left for the CNA to return the calls; however there was no return phone call. CNA #13 no longer worked at the facility. Review of the training, revealed CNA #13 had been checked off on 01/04/2024 on using the Hoyer lift as evidenced by documented Total Lift Competency Test and a post-test written quiz. Observation on 03/08/2024 at 2:33 PM, revealed Licensed Practical Nurse (LPN) #1 removed the dressing from Resident #61's Left lower extremity which revealed a horseshoe shaped skin area on the lateral calf. The margins of the laceration were well-approximated with no signs or symptoms of infection. Adjacent to the horseshoe shaped skin area was a skin tear of the left shin which appeared to be healing without signs or symptoms of infection with an approximate area of 0.3 centimeters (cm) x 0.3 cm remaining to fully heal. LPN #1 cleansed the wounds of the horseshoe shaped skin area of the lateral calf and the skin tear, and applied a treatment of Medi honey covered with an adhesive bordered gauze as per current orders initiated 02/21/2024. During interview with the Director of Nursing (DON), on 03/07/2024 at 5:09 PM, she stated on 02/21/2024 she was made aware via text message that Resident #61 received a new skin tear to the left lower leg caused by CNA #13 transferring Resident #61 without assistance and without the lift because it was quicker. In further interview, she stated CNA #13 was given a Performance Improvement notice related to the improper transfer. Review of the written Performance Improvement / final notice regarding the improper transfer on 02/21/2024, revealed it was signed by CNA #13, Assistant Director of Nursing (ADON) and DON. 2. Review of Resident #74's Face Sheet revealed the facility admitted the resident on 08/21/2021 with diagnoses including Parkinson's Disease, Type-2 Diabetes, and chronic kidney disease. Review of Resident #74's Quarterly Minimum Data Set (MDS) Assessment, dated 12/29/2023, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of eight (8) out of fifteen (15) indicating moderate cognitive impairment. Further review revealed the facility assessed the resident as being totally dependent on staff for transfers. Review of Resident #74's Comprehensive Care Plan, dated 11/08/2021, revised 01/05/2024, revealed a focus of Activities of Daily Living self-care performance deficit related to Parkinson's Disease and impaired mobility. The goal revealed the resident would maintain current level of function through the review date. Interventions initiated 01/05/2024, included the assistance of two (2) staff with the use of a mechanical lift for transfers and a blue Liko lift pad for transfers with the Hoyer lift. Review of Resident #74's Point Click Care (PCC, a software program used for charting) record, under the [NAME] (nurse aide care plan) section, revealed transfers required the Hoyer lift using the blue Liko lift pad. This intervention was tagged to the [NAME] from Resident #74's care plan intervention added by the MDS Coordinator on 01/05/2024. Review of Resident #74's Nurse's Progress Note, dated 01/10/2024 at 2:44 PM, entered by the Director of Nursing (DON) revealed the resident had a new skin impairment, left gluteal fold shearing from lift pad. Review of Resident #74's Nurse's Progress Note, dated 01/10/2024 at 3:14 PM, entered by LPN #2, revealed the resident had shearing to the left gluteal fold related to the lift pad. The resident was changed to a green lift pad. Treatment nurse applied a collagen sheet to the area and covered with a dressing. Nurse Practitioner notified of a new skin injury. Review of Resident #74's Nurse's Progress Note, dated 01/10/2024, at 4:00 PM, entered by the DON, revealed the nurse reviewed the area to the resident's left leg. No drainage noted. No redness or swelling. Resident reports the area did not cause discomfort at this time. Area cleansed and treatment applied from the treatment nurse. In an interview with LPN #2, on 03/07/2024 at 10:30 AM, she stated she was assigned to Resident #74 on 01/10/2024. She reviewed the Progress Note she entered on 01/10/2024 at 3:14 PM, but stated she was not aware of any specific circumstances that happened on 01/10/2024 to cause a problem. She did state CNA #2 told her they needed to get a different lift pad for the resident. In an interview with CNA #2, on 03/07/2024 at 10:40 AM, she stated Resident #74 required the assistance of two (2) staff members for any movement from the bed because of his/her size and mobility issues. She stated a blue lift pad was used to transfer the resident with the Hoyer lift on 01/10/2024. She further stated this was the correct size of lift pad to use at the time, but stated the resident was complaining and seemed to fit tight in the lift pad when being moved so she assisted the resident to bed and removed the lift pad, noting redness at the gluteal fold. She stated she then notified LPN #2 of the skin issue and the need for a larger lift pad for the resident. CNA #2 stated she did not recall who was assisting her with Resident #74 when transferring the resident with the Hoyer lift on the date of the incident. In continued interview with CNA #2 on 03/07/2024 at 10:40 AM, she stated she recalled when the facility contacted Resident #74's family about the new skin injury related to the Hoyer lift pad, they seemed quite upset, and the DON had to intervene. CNA #2 stated the resident was complaining of pain in that same area (left gluteal fold) while sitting in the shower chair and felt like it was pinching his/her leg so they offered to place the resident on a shower bed to reduce pressure and discomfort and the resident declined. CNA #2 then took the State Agency Surveyor to Resident #74's room and the resident was observed to be resting in bed. It was noted there was a green Hoyer lift pad in the wheelchair for use. However, review of the resident's Care plan and [NAME] revealed the resident was to use the blue Liko lift pad for transfers with the Hoyer lift. Interview with Resident #74's son, on 03/07/2024 at 10:14 AM, revealed he was contacted by a nurse on staff at the facility on 01/10/2024, who stated the wrong size lift or pad for the Hoyer lift had been used on the resident. He was unable to recall the nurse who made the call. In further interview, he stated the facility knew they were using a lift pad which was too small and they needed to order a larger one. He further stated it wasn't a major issue initially, but concerned him later because this resident has mobility issues. Further, he did not recall what the staff was doing when they were moving Resident #74 on the day of the incident, but might have been transferring the resident for therapy, bed changes, showers, dressing, etc. He stated no other lift accidents since that time had occurred to his knowledge. During interview with the DON, on 03/07/2024 at 1:45 PM, she stated, on 01/10/2024, the blue pad was being utilized for Resident #74 which was a Proactive (manufacturer) blue pad. However, she stated after the resident had complications with shear on that day, he/she was switched to the green pad with the blue stripe manufactured by Liko. When the DON was questioned why Resident #74's care plan and [NAME] stated a blue Liko pad should be used for the Hoyer lift transfers instead of the green lift pad, she stated the care plan and [NAME] stated the Liko blue lift should be used; however, the facility did not have a blue Liko pad. She further stated the green lift pad which was made by Liko had a blue stripe on it so they called it the blue one. In further interview, she stated Resident #74's Care plan and [NAME] should be revised to say the Liko green pad with the blue stripe. In ongoing interview with the DON, on 03/07/2024 at 1:45 PM, she was questioned related to the reason the incorrect size lift pad was used to transfer Resident #74 on 01/10/2024. The DON explained the blue or green lift pads could be used on any resident provided they meet the weight requirement. Further, she stated the blue lift pad had a weight limit of 600 pounds which was appropriate for the resident; however, the resident seemed to fit tightly in the lift pad and he/she was complaining of discomfort so the decision was made to have staff use the green Liko pad only. During a subsequent interview with the DON, on 03/08/2024 at 6:47 PM, she stated since starting employment as the Director of Nursing in December 2023, she had ensured all staff members were trained on the use of the Hoyer lift. She further stated it was her expectation that all nursing staff followed the Care plan and [NAME] as a reference related to transfer technique, including whether a Hoyer lift was to be used and what type of lift pad to be used. Further, two (2) staff was to assist with all Hoyer lift transfers. When asked how residents were assessed for sling type per manufacturer's guidelines, she stated height, and weight were used to select the color of the mechanical lift pad. She stated she expected staff to utilize the lift pad according to the color indicated on the care plan/[NAME]. Further, she stated staff could work with a nurse to find the right sling pad for the resident if needed In an interview with the Administrator, on 03/08/2024 at 7:09 PM, she stated it was her expectation for staff to follow policies and procedures for use of the Hoyer lift and to ensure correct transfer technique for the safety of the residents.