Willow Ridge Wellness & Rehabilitation

#1 on the new mattress.

She stated she would have the packaging removed right away. In an

on the new mattress did not remove the packaging or extend the bottom sheet so that the resident's

sheet on them such as air mattress but the one on Resident #1's bed was the actual packaging of the mattress.

She said the risk was skin problems. In an interview with CNA D on 01/29/26 at 12:31 PM he said he had been assigned to Resident #1 as her aide. He said he had noticed today at 6:30 AM the mattress was still with the plastic packaging on it but he thought it might have been a specialized type of mattress. He said he did not verify with the nurse because some mattresses came that way and he thought it was part of a compressor bed. He said that the facility worked with different vendors such as hospice and he was not sure when Resident #1 was placed on the new mattress. He stated the risk was rubbing of the skin on the plastic packaging and creating a bed sore. In an interview with the MDS nurse on 01/29/26 at 1:58 PM, revealed Resident #1 was on her angel rounds.

She said angel rounds were when department heads went to different residents' rooms and had a one-on-one time with the resident, made sure they had ice water, the call light was working, and they had no immediate concerns.

She said that she did not notice that Resident #1 was laying on top of the plastic packaging.

She said she did not know how she missed it.

She said she had visited Resident #1 after returning from the hospital (1/19/26) and she did not recall Resident #1 on the mattress with the packaging still on it.

When the nurse was asked why the packaging was not removed before placing Resident #1 on the bed, she said she could not speak on the actions of others and why they did not remove the plastic packaging.

She said the expectation was that the plastic packaging was removed, a fitted or bottom sheet was placed on the mattress prior to putting the resident in bed.

She said that the risk to Resident #1 was skin breakdown.

Interview with DON on 01/29/26 at 2:42 PM revealed she was not aware of Resident #1 situation of being laid on plastic packaging.

She said the expectation was that packaging was removed off the mattress and bed was made up with clean linen.

She said the risk to the resident was skin breakdown.

She said all nursing staff were responsible.

Interview with the Administrator on 01/29/26 at 2:58 PM, she said they had just gotten new mattresses for the facility in the past 4 days.

She said she would get the DON to complete a skin assessment on Resident #1.

She said the expectation was that the staff would remove the mattresses out of the plastic packaging before placing them on the mattress.

She said that she would also start an in-service on the new mattresses because all the residents were getting new mattresses.

She said except for Resident 1 all the residents that had already gotten a new mattress did not have the plastic packaging still on.

She said she had gone around to check the rooms.

She said due to plastic packaging being non-breathable plastic, the risk to the residents was potential skin breakdown.

She said all residents had a right to a comfortable environment.

Record review of facility policy titled Residents Rooms and Environment revised 08/2020 revealed Facility Staff aim to create a personalized, homelike atmosphere, paying close attention to thefollowing:A.

Cleanliness and order;B.

Private closet space in each resident room;C.

Lighting that is comfortable (minimum glare) yet adequate (suitable to the task);D.

Personalized furniture and room arrangements;E.

Pleasant, neutral scents;F.

Comfortable levels of ventilation;G.

Comfortable temperatures; andH.

Comfortable noise levels. II.

The resident will be provided with a bed of proper size and height for safety and convenienceof the resident.