Health inspection·June 23, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few breakdown.infection. There were no interventions added to assist Resident 1's diabetic ulcers in the healing process on 5/8/25. Interventions were not added until 5/28/25 (21 days after Resident 1's wounds were first identified).During a concurrent interview and record review, on 5/28/25 at 4:05 p.m. with Director of Nursing (DON). Resident 1's AREA, dated 5/7/25 was reviewed. DON confirmed Resident 1 had a wound to the right heel and a closed blister to the left heel which were present upon admission with no measurement or description documented. Resident 1's Treatment Administration Record, (TAR) dated May 2025 was reviewed. After reviewing the TAR, DON stated no treatments were performed for Resident 1's right heel or left heel wounds from 5/7/25 to 5/16/25 (9 days). DON reviewed Resident 1's physicians' orders. DON stated the admissions nurse did not obtain treatment orders from the physician to treat the resident right heel and left heel. DON stated no treatments to the right and left heel were documented as being performed from 5/7/25 to 5/16/25 . DON stated, if it [treatment] is not documented it [treatment] is not done. Resident 1's care plans initiated 5/8/25 were reviewed. DON stated no wound care interventions were developed for the wounds to Resident 1's right heel or left heel on the day the care plan was developed. During a concurrent interview and record review, on 6/23/25 at 11:44 a.m. with DON, DON stated a resident's skin should be assessed and wounds should be measured and documented upon admission. DON stated measurements of wounds should be taken when identified to monitor if the wound is worsening. DON stated the resident physician should be notified of the wounds and treatment orders should be obtained and placed in the medical record to be implemented. DON stated a resident with wounds should be placed on the wound doctor (a healthcare professional with specialized training and experience in the care and treatment of acute, chronic, and non-healing wounds) services to be evaluated by the wound doctor weekly. DON stated a care plan should be created and implemented when residents have wounds. DON stated a resident with diabetic wounds to the heels would have interventions including placing a hi-lift boot (heel offloading boot meant to protect and care for bony prominence) while in bed, wound consult, treatments as order, and monitoring for signs and symptoms of infection. DON stated Resident 1's right and left heel wounds were not measured upon admission. DON stated a care plan for Resident 1's right and left heel wounds were not created upon admission, DON confirmed care plan interventions were created on 5/28/25 (21 days after wounds were identified). DON stated wound care orders were not placed in Resident 1's medical record until 5/16/25 (9 days after admission) DON stated there was no documentation of Resident 1's right or left heel wound treatments being performed until 5/16/25, 9 days after admission. During a review of the facility's P&P titled, Wound Care, revised October 2010, the P&P indicated, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation 1. Verify that there is a physician's order for this procedure. 2. Review the resident's care plan to assess for any special needs of the resident. Documentation The following information should be recorded in the resident medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. 10. The signature and title of the person recording the data. Reporting .2. Report other information in accordance with facility policy and professional standards of practice.During a review of the facility's P&P titled, admission Assessment and Follow Up: Role of the Nurse, lasted revised September 2012, the P&P indicated, The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purpose of managing the resident, initiating the care plan, and completing required assessments . e. Skin assessment . 12. Contact the Attending Physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056294 If continuation sheet Page 2 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056294 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Joaquin Nursing Center and Rehabilitation Cent 3601 San Dimas Bakersfield, CA 93301 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 based on these findings. Documentation The following information should be recorded in the resident's medical record: . 5. Orders obtained from the physician. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056294 If continuation sheet Page 3 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056294 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Joaquin Nursing Center and Rehabilitation Cent 3601 San Dimas Bakersfield, CA 93301 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm Based on interview and record review, the facility failed to follow their policy and procedures (P&P) titled, Prevention of Pressure Injuries (PI -localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), Wound Care, and admission Assessment and Follow Up: Role of the Nurse, for one of three sampled residents (Resident 1) when the physician was not notified and treatment orders obtained, a care plan was not developed and implemented, wound measurements were not completed, and an individualized turning/repositioning schedule was not determined, when the resident was admitted with a coccyx (tailbone) PI. These failures resulted in Resident 1 not being provided wound care for nine days and the worsening of Resident 1's pressure injury.Finding:During a review of Resident 1's Admission/readmission Evaluation/Assessment (AREA), (AREA - document used by the facility when a resident is admitted /readmitted to document the assessment including skin assessment) dated 5/7/25 (admission date), the AREA indicated, Reason for admission: Skilled needs, wound care. The AREA indicated Resident 1 was incontinent of bladder and required assistance with activities of daily living (ADLs - refers to basic self-care tasks): bathing, dressing, toileting, and bed mobility. The AREA indicated Resident 1 had a pressure injury to the coccyx (tailbone). There was no documentation measurements or a description of Resident 1's pressure injury to the coccyx.During a review of Resident 1's Braden Scale for Predicting Pressure Ulcer Risk Evaluation, (Braden Scale is risk assessment tool used to predict the likelihood of a resident developing pressure injuries with the scores ranging from 6 - 23, with the lower the score the higher the risk for developing a pressure injury) dated 5/7/25, Resident 1's Braden score was 14 (score of 13-14 indicates a moderate risk for developing a pressure injury).During a review of Resident 1's care plan (comprehensive, personalized document that outlines the specific needs of an individual requiring care, detailing the type of support, how it will be provided/interventions, and the goals of the care) initiated 5/8/25, with the focus on Skin: [Resident 1] is at risk for skin breakdown related to edema (swelling of the body tissue), impaired mobility, pain, Braden Score :14. The care plan interventions included, Assist to turn and reposition as indicated/tolerated. Keep skin clean and dry to the extent possible. The care plan did not include an individualized turning/repositioning schedule. During a review of Resident 1's Minimum Data Set, (MDS - a comprehensive assessment tool to evaluate the functional capabilities and health needs of residents) dated 5/12/25, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status- standardized assessment tool used to evaluate the mental processes that allow individuals to think, learn, and remember) score was 11 (score between 8 to 12 indicates moderately impaired cognition). The MDS indicated Resident 1 was dependent (helper does all the effort) for toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement), and required substantial/maximal assistance (helper does more than half the effort) with rolling to the left and to the right (the ability to roll from lying on back to left and right side and return to lying on back on the bed). The MDS indicated Resident 1 had one or more unhealed pressure injuries, one unstageable pressure injury (obscured full - thickness skin and tissue loss. Full - thickness skin and tissue loss in which the extent of tissue damage within the PI cannot be confirmed because it is obscured by slough [yellow or white material consisting of dead cells which attaches to the wound bed] or eschar [dead tissue that forms over healthy skin]. If slough or eschar is removed, a Stage 3 [Full-thickness loss of skin, in which adipose (fat) is visible] or Stage 4 [Full-thickness skin and tissue loss with exposed muscle, tendon (flexible tissue, similar to a rope), ligament [a band of tissue that connects bones, joints or organs], cartilage [a strong, flexible connective tissue that protects Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056294 If continuation sheet Page 4 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056294 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Joaquin Nursing Center and Rehabilitation Cent 3601 San Dimas Bakersfield, CA 93301 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Actual harm Residents Affected - Few joints and bones] or bone are visible in the pressure injury] are revealed) presenting as a deep tissue injury (intact or non-intact skin with localized area of persistent non-blanchable [the skin does not turn white when touched with a finger] deep red, maroon, purple discoloration or epidermal [outer layer of skin] separation revealing a dark wound bed or blood-filled blister [raised skin filled with fluid]) present on admission.During a review of Resident 1's Skin & Wound Evaluation (SWE - document used by the facility to document the resident's skin condition), dated 5/15/25, the SWE indicated Resident 1 had a stage 4 pressure injury present on admission. There was no documentation of the location of the PI. The SWE indicated the wound measured: area 16.8 centimeters squared (cm2 - unit of measurement), length 8.2 centimeters (cm - unit of measurement), and width 5.2 cm. No depth of the wound was documented. During a review of Resident 1's SWE, dated 5/21/25, the SWE indicated Resident 1 had a stage 4 pressure injury to the coccyx, present on admission. The SWE indicated the wound measured: area 9.0 cm2, length 4.8 cm, and width 3.0 cm. No depth of the wound was documented. During a review of Resident 1's SWE, dated 5/30/25, the SWE indicated Resident 1 had a stage 4 pressure injury to the coccyx, present on admission. The SWE indicated the wound measured: area 35.8 cm2, length 8.6 cm, width 7.3 cm, and depth 1.0 cm. The SWE indicated Resident 1's pressure injury was deteriorating and infection was suspected. No depth of the wound was documented. During a review of Resident 1's care plan initiated 5/27/25, with the focus on Skin: (Resident 1) has a pressure ulcer to (coccyx) and is at risk for further breakdown and or slow, delayed healing related to, the care plan interventions included: Pressure reduction cushion for chair. and Pressure reduction mattress for bed. There was no care plan interventions to turn reposition the resident. During a review of Resident 1's care plan with the focus on Skin: (Resident 1) has a pressure ulcer to coccyx and is at risk for further breakdown and or slow, delayed healing related to Diabetes (medical condition that leads to high blood sugar levels), incontinence of bladder incontinence of bowel, initiated 5/28/25. The care plan interventions included: Pressure reduction cushion for chair. and Air mattress No care plan interventions were added to turn and reposition at a specific frequency. During a review of Resident 1 Task Turn and Reposition, (TTR - document used by the facility to document when the staff reposition a resident) for dates 5/7/25 to 5/29/25, the following was noted:On 5/8/25, the TTR indicated Resident 1 was turned or repositioned two times within that 24-hour period On 5/9/25, the TTR indicated Resident 1 was turned or repositioned three times within that 24-hour period On 5/10/25, the TTR indicated Resident 1 was turned or repositioned four times within that 24-hour period On 5/11/25, the TTR indicated Resident 1 was turned or repositioned two times within that 24-hour period On 5/12/25, the TTR indicated Resident 1 was turned or repositioned three times within that 24-hour period On 5/13/25, the TTR indicated Resident 1 was turned or repositioned three times within that 24-hour period On 5/14/25, the TTR indicated Resident 1 was turned or repositioned three times within that 24-hour period On 5/15/25, the TTR indicated Resident 1 was turned or repositioned three times within that 24-hour period On 5/16/25, the TTR indicated Resident 1 was turned or repositioned three times within that 24-hour period On 5/17/25, the TTR indicated Resident 1 was turned or repositioned four times within that 24-hour period On 5/18/25, the TTR indicated Resident 1 was turned or repositioned three times within that 24-hour period On 5/19/25, the TTR indicated Resident 1 was turned or repositioned three times within that 24-hour period On 5/20/25, the TTR indicated Resident 1 was turned or repositioned three times within that 24-hour period On 5/21/25, the TTR indicated Resident 1 was turned or repositioned two times within that 24-hour period On 5/22/25, the TTR indicated Resident 1 was turned or repositioned four times within that 24-hour period On 5/23/25, the TTR indicated Resident 1 was turned or repositioned three times within that 24-hour period On 5/24/25, the TTR (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056294 If continuation sheet Page 5 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056294 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Joaquin Nursing Center and Rehabilitation Cent 3601 San Dimas Bakersfield, CA 93301 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Actual harm Residents Affected - Few indicated Resident 1 was turned or repositioned three times within that 24-hour period On 5/25/25, the TTR indicated Resident 1 was turned or repositioned two times within that 24-hour period On 5/26/25, the TTR indicated Resident 1 was turned or repositioned four times within that 24-hour period On 5/27/25, the TTR indicated Resident 1 was turned or repositioned two times within that 24-hour period On 5/28/25, the TTR indicated Resident 1 was turned or repositioned three times within that 24-hour period During a concurrent interview and record review, on 5/28/25 at 4:05 p.m. with Director of Nursing (DON). Resident 1's AREA dated 5/7/25, the AREA indicated Resident 1 had a pressure injury to coccyx. The licensed nurse did not document measurements or that staging (system used to classify the severity of the PI based on the depth of the tissue damage) of the PI was done. Resident 1's Treatment Administration Record (TAR) (TAR) dated May 2025 was reviewed. After reviewing the physician's orders, DON stated there were no physician's orders to treat the coccyx PI and therefore no treatment of Resident 1's pressure injury was performed from 5/7/25 to 5/15/25 (9 days). DON stated the admissions nurse did not obtain treatment orders from the medical doctor to perform treatments to the coccyx PI. DON stated, If it (treatment) is not documented it (treatment) is not done. Resident 1's care plans were reviewed. DON stated no actual pressure injury care plan was developed when the PI to the coccyx was first identified on 5/7/25. The care plan for the coccyx PI was not developed until 5/27/25. During a concurrent interview and record review, on 6/23/25 at 11:44 a.m. with DON, DON stated a resident's skin should be assessed and wounds should be measured and documented upon admission. DON stated measurements should be taken when identified to monitor if the wound is improving or worsening. DON stated the resident's physician should be notified of the wounds and treatment orders should be obtained and placed in the resident's medical record to be implemented. DON stated a resident with wounds should be placed on the wound doctor (a healthcare professional with specialized training and experience in the care and treatment of acute, chronic, and non-healing wounds) services to be evaluated weekly. DON stated a care plan should be created and implemented. DON stated a resident with pressure injuries on the coccyx should have care plan interventions including, turning and repositioning every 2 hours and as needed, keep the resident clean and dry, air mattress and specialized cushion while up in chair. DON stated Resident 1's pressure injury was not measured upon admission. DON stated a care plan for Resident 1's pressure injury was not created upon admission. DON confirmed the care plan for the coccyx PI was created on 5/27/25. DON stated wound care orders were not placed in Resident 1's medical record until 5/16/25 (9 days after admission) DON stated there was no documentation the nurses treated Resident 1's pressure injury on 5/7/25, 5/8/25, 5/9/25, 5/10/25, 5/11/25, 5/12/25, 5/13/25, 5/14/25, 5/15/25. Nurses documented treatment to the coccyx wound on 5/16/25. During a review of the facility's P&P titled, Prevention of Pressure Injuries, revised April 2020, the P&P indicated, The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Risk Assessment 1. Assess the resident on admission (within eight hours) for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any change of condition. Skin Assessment 1. Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors, and prior to discharge. 3. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs. a. Identify any signs of developing pressure injuries (i.e., non-blanchable erythema). Inspect pressure points (sacrum, heels, buttocks, coccyx, .); . e. Reposition resident as indicated on the care plan. Prevention Skin Care 1. Keep the skin clean and hydrated. 2. Clean promptly after episodes of incontinence. Mobility/repositioning 1. Reposition all residents with or at risk of pressure injuries on an individualized schedule, as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056294 If continuation sheet Page 6 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056294 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Joaquin Nursing Center and Rehabilitation Cent 3601 San Dimas Bakersfield, CA 93301 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete determined by the interdisciplinary care team. 2. Choose a frequency for repositioning based on the resident's risk factors and current clinical practice guidelines. 3. Teach resident who can change positions independently the importance of repositioning. Provide support devices and assistance as needed. Remind and encourage residents to change positions. Monitoring 1. Evaluate, report and document potential changes in skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis.During a review of the facility's P&P titled, Wound Care, revised October 2010, the P&P indicated, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation 1. Verify that there is a physician's order for this procedure. 2. Review the resident's care plan to assess for any special needs of the resident. Documentation The following information should be recorded in the resident medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. 10. The signature and title of the person recording the data. Reporting . 2. Report other information in accordance with facility policy and professional standards of practice.During a review of the facility's P&P titled, admission Assessment and Follow Up: Role of the Nurse, lasted revised September 2012, the P&P indicated, The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purpose of managing the resident, initiating the care plan, and completing required assessments . e. Skin assessment . 12. Contact the Attending Physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings. Documentation The following information should be recorded in the resident's medical record: . 5. Orders obtained from the physician. Event ID: Facility ID: 056294 If continuation sheet Page 7 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056294 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Joaquin Nursing Center and Rehabilitation Cent 3601 San Dimas Bakersfield, CA 93301 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment for one of three sampled residents (Resident 2 ) when:1. A low air loss mattress (a specialized medical mattress designed to prevent and treat pressure injuries [PI - localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear and/or friction] by providing a combination of air circulation and pressure redistribution) was improperly installed. This failure resulted in Resident 2 hitting his head.2. The wheelchair was not maintained and could not be properly cleaned and sanitized. This failure had the potential for Resident 2 to be exposed the infection and bacteria.Findings:1. During a review of Resident 2's Minimum Data Set, (MDS - a comprehensive assessment tool to evaluate the functional capabilities and health needs of residents) dated 5/18/25, the MDS indicated, Resident 2's BIMS (Brief Interview for Mental Status - standardized assessment tool used to evaluate the mental processes that allow individuals to think, learn and remember) score was 12 (a score of 8 to 12 indicates moderately impaired cognition).During a concurrent observation and interview, on 5/28/25 at 1:46 p.m. with Resident 2 in Resident 2's room, Resident 2 stated his low air loss mattress was installed wrong and the machine has hit him in the head a few times. The machine (the air hose connectors) was observed at the head of the bed on the floor. Resident 2 stated he has been here for two weeks and the bed has been like this. Resident 2 stated he made a certified nursing assistant (CNA) aware and the CNA said he would change it but the CNA never changed the set up of the low air loss mattress.During a concurrent observation and interview, on 5/28/25 at 2:20.p.m. with Maintenance Director (MD), in Resident 2's room. MD stated he does assist in installing the low air loss mattresses when a nurse asks. MD stated he helps strap the mattress to the bed frame and plugs it in. MD confirmed Resident 2's low air loss mattress and the air hose connectors were located at the head of the bed and resting on the floor. During an interview on 5/28/25 at 3:54 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated low air loss mattress' air hose connectors should be placed at the foot of the bed. During a review of the facility provide manual titled, A10, Low Air-Loss Mattress Replacement System With Alternating Pressure, undated, the manual indicated, Installation 1. Place the mattress directly on the bed frame, with the air hose connectors positioned at the footboard. 2. Hang the pump onto the bed board (footboard side) .2. During a concurrent observation and interview, on 5/28/25 at 1:46 p.m. with Resident 2 in Resident 2's room, Resident 2 stated the facility provide him with his current wheelchair. Resident 2 stated he received the wheelchair with cracks and a right arm rest peeling. Resident 2 stated he put the hot pink duct tape on the left arm rest. During a concurrent observation and interview, on 5/28/25 at 2:20.p.m. with MD, in Resident 2's room, MD confirmed Resident 2's wheelchair right arm rest was cracked and peeling and the left arm rest had hot pink duct tape on more than half of the arm rest. DM stated he could not say if Resident 2's wheelchair arm rest could be sanitized. During an interview on 5/28/25 at 3:54 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated residents with cracked or peeling arm rest on wheelchairs, should have the arm rest replaced. LVN 1 stated cracked and peeling arm rest could not be sanitized.During a review of the facility policy and procedure (P&P) titled, Infection Prevention and Control Program, revised October 2018, the P&P indicated, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 11. Prevention of Infection . (8) following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC). Event ID: Facility ID: 056294 If continuation sheet Page 8 of 8