**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and family interview, record review and review of the facility policy Pressure Ulcer Prevention and Assessment the facility failed to ensure Resident #330 was turned and repositioned at least every two hours to relieve pressure on his buttocks, failed to maintain an intact, ordered dressing in place to his sacrum and failed to ensure the setting on his low air loss (LAL) mattress was adjusted to the proper setting demonstrating a lack of care and services to prevent the development of a deep tissue pressure injury (persistent non-blanchable deep red, maroon or purple discoloration intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue). In addition, the facility failed to ensure Resident #335's pressure ulcers and injuries were accurately and thoroughly evaluated, measured, and documented in the medical record and Resident #52 was adequately repositioned to provide pressure relief to his wound areas. This affected three residents (Resident's #52, #330, #335) out of four residents reviewed for pressure ulcers. The facility census was 80. Actual Harm occurred to Resident #330 on 03/14/23 when Resident #330, who returned to the facility from a hospitalization on 03/07/23 with a documented excoriated buttocks and groin area with barrier cream in place, was assessed and observed by Wound Nurse Practitioner (WNP) #925 and found to be laying on a hard, LAL mattress not properly adjusted to the required settings, and Resident #330 had developed a deep pressure injury on his coccyx radiating to the right buttock. Findings include: 1.Review of Resident #330's medical record revealed an admission date of 01/14/23 and a re-entry date of 03/07/23 after being in the hospital with the diagnoses of urinary tract infection and clostridium difficile (a bacteria that can cause diarrhea and inflammation of the bowel) . Resident #330's additional diagnoses included enterocolitis due to clostridium difficile (C Diff), acute kidney failure and dehydration. Review of Resident #330's Braden Scale for Predicting Pressure Sore Risk, dated 01/14/23, revealed Resident #330 was at low risk for developing a pressure ulcer, injury. Review of Resident #330's hospital Physician Orders and Transfer of Care Form, dated 02/28/23 through 03/07/23, included Resident #330 was incontinent of bladder and bowel. Resident #330 was alert, oriented and cooperative. Resident #330's skin was intact, he had excoriation (an abraded area of the skin) on his bottom and groin, and barrier cream was applied. Review of Resident #330's physician orders, dated 03/07/23, revealed protective barrier cream ointment topically to peri-area (perineal area) after each incontinent episode. This order was discontinued on 03/08/23 and a new order written dated 03/08/23 at 8:15 A.M. for a treatment to buttocks and perineal area, cleanse with wound cleanser, apply Triad (adheres to wet skin, keeping the wound covered and protected from incontinence) and cover buttocks with a large sacral dressing for protection, change three times a week and as needed. Review of Resident #330's Initial Wound Assessment Documentation dated, 03/07/23 at 7:44 P.M., included Resident #330's buttocks and groin were excoriated with no open areas. Review of Resident #330's admission Minimum Data Set (MDS) 3.0 assessment, dated 03/07/23, revealed Resident #330 had moderate cognitive impairment. Resident #330 required extensive assistance of one staff member for bed mobility and toilet use and required extensive assistance of two staff members for transfers. Resident #330 was frequently incontinent of urine and occasionally incontinent of bowel. Resident #330 did not have a pressure ulcer. Review of Resident #330's physician orders, Medication Administration Record (MAR) and Treatment Administration Record (TAR), State Tested Nursing Assistant (STNA) charting, care plan, and progress notes dated 03/07/23 through 03/14/23, did not reveal documentation Resident #330 had physician orders to be turned and repositioned every two hours or evidence Resident #330 was turned and repositioned every two hours. Further review of the progress notes did not reveal documentation Resident #330 refused to be turned and repositioned. Review of Resident #330's TAR, dated 03/08/23, revealed he did not receive the treatment orders dated 03/08/23 at 8:15 A.M. for a treatment to buttocks and perineal area, cleanse with wound cleanser, apply Triad and cover buttocks with a large sacral dressing for protection, change three times a week and as needed. Review of Resident #330's care plan, dated 03/08/23, included Resident #330 had impaired skin integrity with risk of pain and infection related to fragile skin and incontinence MASD (moisture associated skin damage) to buttocks due to loose stools from clostridium difficile. Resident #330 would have pain managed as evidenced by no complaints of pain, Resident #330 would have wound resolved, Resident #330's wound would be without signs and symptoms of infection, Resident #330's wound would decrease in size as noted measurements. Care plan Interventions dated 03/08/23 included to apply barrier cream after each incontinence cleansing, check skin with showers/baths and report abnormalities to the physician as indicated; a low air loss mattress, notify physician and resident, resident representative of change in condition, positioning interventions, appliances, wound treatments per protocol and physician orders. Review of Resident #330's general progress notes and assessments, dated 03/10/23 through 03/13/23, revealed no documentation of characteristics of a wound or reddened area on Resident #330's coccyx, sacral area or buttocks including measurements, color, drainage. Review of Resident #330's skilled progress notes dated, 03/10/23 at 11:09 A.M., revealed Resident #330 had no change to skin or current impairments. Review of Resident #330's STNA charting for skin observation, dated 03/10/23 at 11:38 A.M., revealed Resident #330 had a new skin impairment, red area. The new skin impairment, red area was reported to the nurse. This charting did not indicate what area of the body the STNA noted the red area of skin impairment. Review of Resident #330's skilled progress notes dated, 03/11/23 at 5:47 P.M. revealed Resident #330 had no change to skin or current impairments, dressing on left buttock wound. Review of Resident #330's skilled progress notes dated, 03/12/23 at 5:59 P.M., revealed Resident #330 had no change to skin or current impairments, wound on sacrum, coccyx, dressing present. Review of Resident #330's skilled progress notes dated, 03/13/23 at 6:48 P.M., revealed no change to skin or current impairments. Review of Resident #330's Wound Evaluation, dated 03/14/23, and completed by WNP #925 included findings that Resident #330 had a pressure injury, Deep Tissue Injury, on his coccyx radiating to the right buttock. The measurements were a length of 15 centimeters (cm), width seven cm, and depth at least 0.1 cm. Resident #330 had a red, open area directly over the coccyx with a reddish-purple linear discoloration radiating from the right buttock to the right ischial area, area was all measured as one. Eighty percent of the measured area was intact but discolored. Treatments to consider included to turn and reposition every two hours, pressure reducing mattress, alternating, pressure redistribution cushion to all seated surfaces. Treatment for the pressure ulcer was to cleanse with wound cleanser, apply xeroform to the open area over the coccyx. Then apply a large sacral foam dressing. Change three times a week and as needed. Ensure static mode was turned off and weight was consistent with patient's weight. Further review of the wound evaluation included resident was admitted to the facility to undergo rehab and family was present during the exam. Wife #950 stated resident was having some discomfort and a pillow was placed underneath Resident #330's buttocks. It was explained to Wife #950 the pillow negated the offloading properties of the specialized mattress that Resident #330 was on, and the pillow could be used to help position him so he was offloaded on his buttocks but should not come in contact with the wound itself. Resident #330 had a dark, purplish red linear line along the right buttock consistent with possible pillow coming in contact with this area or folded bedding. There was a small superficial area directly over the coccyx, the entire area was measured as one given the discoloration throughout. The above treatment would be applied using the large sacral foam to incorporate the entire area. Resident #330 was currently treated for clostridium difficile (C Diff) and this placed him at a greater risk of further tissue breakdown and posed a barrier to resolution. The large sacral foam should help protect the area from exposure. The facility would ensure the low air loss mattress was not set on static position and coincided with his current weight which was 204 pounds. Recommend limiting time in chair to less than two-hour intervals and Resident #330 could rotate back and forth between the bed and chair frequently throughout the day. Review of the manufacturer instructions for Resident #330's LAL mattress included the pump and mattress system was indicated for the prevention and treatment of any and all stage pressure ulcers when used in conjunction with a comprehensive pressure ulcer management program. The instructions included to determine the patient's weight and set the control knob to that weight setting on the control unit. Further review included to press the static button to shift between alternating mode and static mode. In alternating mode, the air cells will alternate in ten-minute cycles. When in static mode, the mattress provides a firm surface that makes it easier for the patient to transfer or reposition. The static mode will help ensure the patient does not bottom out when in a sitting position. Observation on 03/13/23 at 8:22 A.M. revealed Resident #330's wife called surveyor to Resident #330's room. Wife #950 stated Resident #330's incontinence brief was not changed and now his rear end was raw. Wife #950 stated she registered a complaint with Resident #330's nurse and aide, but she did not know what their names were. Wife #950 stated this happened on 03/08/23 and 03/10/23, and Wife #950 stated she did not know who the nurse was those days. Wife #950 stated the aide and Licensed Social Worker (LSW) #881 reported it to the nurse. Wife #950 indicated Resident #330 was very restless and his incontinence brief was not changed timely during the night. Observation on 03/13/23 at 8:30 A.M. of Resident #330's buttock and sacral area with Registered Nurse (RN) #910 revealed Resident #330's incontinence brief was wet with urine. Resident #330 did not have a dressing on his sacral or buttock area. Observation of Resident #330 revealed he had an open area with a pink wound bed on his coccyx which was approximately the size of a nickel, and a dark red and purple line extending down his right buttock. Further observation revealed Resident #330's buttocks were excoriated, had open areas, and barrier cream was noted on buttocks. Observation on 03/13/23 at 9:48 am revealed Resident #330 lying on his back in bed. There was no observation of staff turning and repositioning Resident #330 or encouraging Resident #330 to turn and reposition. Interview on 03/13/23 at 9:48 A.M. with Wife #950 revealed on 03/09/23 or 03/10/23 the aides changed Resident #330's incontinence brief and reported the red and raw areas to the nurse. Wife #950 stated when she arrived on 03/10/23 Resident #330's buttocks was very red and sore, and it was reported to the nurse. Wife #950 stated the nurse did not come to the room to evaluate Resident #330's buttocks. Wife #950 indicated Resident #330's incontinence brief was changed, and his red buttocks addressed only after she arrived on 03/10/23. Wife #950 stated today (03/13/23) Resident #330's buttocks was still very red and very sore. Wife #950 indicated Resident #330 did not have a bed sore when he was admitted to the facility. Wife #950 stated cream was put on Resident #330's buttocks when he was changed. Wife #950 stated she was pretty pissed off about the way Resident #330's buttocks looked now. Observation on 03/13/23 at 11:00 A.M., 12:00 P.M., 2:00 P.M. revealed Resident #330 lying on his back in bed. There was no observation of staff turning and repositioning Resident #330 or encouraging Resident #330 to turn and reposition. Observation on 03/14/23 at 10:09 A.M. revealed Resident #330 lying on his back in bed. There was no observation of staff turning and repositioning Resident #330 or encouraging Resident #330 to turn and reposition. Observation on 03/14/23 at 10:09 A.M. of Resident #330 with Wound Nurse Practitioner (WNP) #925 revealed Resident #330's coccyx had an open area with a pink wound bed. Resident #330 had a dark purple line approximately one-half inch wide and one and one-half inch long along his right buttock and ischial area which did not blanche. WNP #925 stated the purple area was due to some kind of pressure injury. Wife #950 was at the bedside and stated the staff did not turn and reposition Resident #330 and he was always lying on his back. Wife #950 stated staff got Resident #330 up for a little bit on 03/13/23, but otherwise he was lying on his back all the time. Observation revealed Resident #330 was lying on his back with a pillow under his buttocks. WNP #925 stated the pillow was causing pressure to the area and should not be under the buttocks. WNP #925 noted the LAL mattress setting was at 350 which was the highest level, and the static button was on which prevented the LAL mattress from redistributing the pressure. WNP #925 stated the LAL mattress setting should be according to weight and should be set at 180 and not 350 and the static button should be off. WNP #925 felt the bed and stated the bed was very hard under Resident #330's buttock and sacral area. The surveyor confirmed the bed was very hard under Resident #30's buttock and sacral area. WNP #925 stated the staff needed to be educated on the proper settings for the LAL mattress. Interview on 03/15/23 at 3:55 P.M. with Registered Nurse (RN) #910 revealed Resident #330 was admitted at the end of her shift and his buttocks and groin were excoriated, a little red, but Resident #330 had no open areas on his bottom. RN #910 stated Resident #330 was admitted with C Diff and his wife was in the room when the admission skin assessment was completed. RN #910 stated Resident #330's wife arrived every day at 8:00 A.M. and stayed until about 6:00 P.M. Interview on 03/16/23 at 4:38 P.M. with Wife #950 revealed she did not know who put the pillow under Resident #330 when WNP #925 visited her husband. Wife #950 stated one of the aides placed the pillow under Resident #330's buttocks. Wife #950 stated she did not place the pillow under Resident #330 to relieve pain he was having on his bottom. Interview on 03/20/23 at 8:07 A.M. of State Tested Nursing Assistant (STNA) #826 revealed she often was assigned to care for Resident #330. STNA #826 stated she was not working when Resident #330 was admitted but following a night shift she changed Resident #330's incontinence brief and his bottom was red and bleeding. STNA #826 stated she did not remember which day this occurred but it happened within the first week Resident #330 was re-admitted to the facility on [DATE]. STNA #826 stated Resident #330's incontinence brief was soaked, the bed was soaked, his bottom was red and bleeding and it was horrible. STNA #826 indicated she reported the situation to the nurse and the Director of Nursing (DON), and the night shift aide was written up. STNA #826 stated she could not remember the aides name but did not think the aide still worked at the facility. STNA #826 stated she put pillows under Resident #330's side and buttocks to keep the pressure off. Interview on 03/20/23 at 8:21 A.M. with LSW #881 confirmed he spoke with Wife #950 and the nurse supervisor (Licensed Practical Nurse (LPN) #884) regarding Resident #330's diarrhea and his bottom being red and raw. LSW #881 confirmed Wife #950 was upset about Resident #330's red and raw bottom. Interview on 03/20/23 at 10:08 A.M. with Licensed Practical Nurse/Unit Manager (LPN/UM) #813 revealed STNA #826 reported Resident #330's incontinence brief and bed were soaked and Resident #330's bottom had an open area. LPN/UM #813 stated she could not remember which day this happened, but it was in the morning. LPN/UM #813 stated she entered Resident #330's room, looked at his bottom, and it was excoriated. LPN/UM #813 stated she looked at the initial wound assessment, and there was nothing else significant. LPN/UM #813 stated Triad cream was applied to Resident #330's buttocks. LPN/UM #813 indicated Resident #330's buttocks were red but not bleeding, and the purple line was not observed on Resident #330's bottom. Interview on 03/20/23 at 1:24 P.M. with LPN/UM #813 and the Director of Nursing (DON) revealed LPN/UM #813 stated she reported the lack of timely incontinence care for Resident #330 to the nurse on the floor but did not remember who she talked to. LPN/UM #813 indicated she told the nurse to pass it on in report to the next shift to make sure the STNAs were providing incontinence care and doing last rounds to check on the residents before going home. LPM/UM #813 stated the aides should be giving report to each other. LPN/UM #813 stated she did not talk to the night shift aide about Resident #330's incontinence care but told the DON about it. The DON stated she did not talk to the aide about Resident #330's incontinence care or write the aide up for customer service because she could not prove Resident #330 was not wet at the beginning of the shift because he was not checked by STNA #826 until 8:30 A.M. 2. Review of Resident #335's medical record revealed an admission date of 03/08/23 and diagnoses including ventricular tachycardia, acute respiratory failure with hypoxia and type two diabetes mellitus. Review of Resident #335's admission Assessment and Baseline Care Plan, dated 03/08/23, revealed Resident #335 arrived via a cot and was alert to self, person, place, and time. Resident #335 required partial or moderate assistance for bed mobility. Resident #335 required assistance of two staff and used a mechanical lift for transfers. Resident #335 was occasionally incontinent of bowel and bladder. Resident #335 had an unstageable pressure ulcer to the sacrum and measurements were length four centimeters (cm) and width of three cm, with slough (necrotic, dead tissue) and MASD (moisture associated skin damage) surrounding. Review of Resident #335's hospital discharge instructions titled Gold Form: Provider Orders, dated 03/08/23, included Resident #335 had an evolving deep tissue pressure injury on his sacrum, buttocks and the wound measured a length of 12 cm, and a width of 10 cm. The form further stated Resident #335 had a wound site of peri wound skin on bilateral ischium and both had intact deep tissue pressure injuries. The right ischium measured length of four centimeters (cm), width of two cm and the left ischium measured a length of two cm and a width of two cm. Review of Resident #335's care plan, dated 03/08/23, included Resident #335 had impaired skin integrity with risk of pain and infection. Resident #335 was admitted to the facility with a pressure ulcer on his sacrum. Resident #335's wound would be without signs and symptoms of infection. Resident #335's wound would decrease in size as noted by measurements. Interventions included apply barrier after each incontinence cleansing and wound treatments per protocol and physician orders. Review of Resident #335's physician orders on 03/09/23 revealed treatment, sacrum, cleanse with wound cleanser, apply Triad and then cover with xeroform, cover with sacral dressing, and change three times a week and as needed. Review of Resident #335's physician orders dated 03/08/23 through 03/13/23 did not reveal orders to turn and reposition Resident #335 every two hours or orders for a LAL mattress. Orders on 03/09/23 revealed orders for a pressure redistributing mattress. Observation on 03/13/23 at 3:09 P.M. of Resident #335 with Registered Nurse (RN) #837 revealed Resident #335 was lying on his back in bed and the head of the bed was elevated approximately 45 degrees. Resident #335 stated he had diarrhea and needed cleaned up. RN #837 stated she would make sure that happened. Observation on 03/13/23 at 3:35 P.M. of Resident #335 revealed he was lying in bed on his back and the head of the bed was elevated 45 degrees. Resident #335 stated his incontinence brief had not been changed. Observation on 03/13/23 at 4:13 P.M. of State Tested Nursing Assistant (STNA) #922 revealed STNA #922 exited another resident room at the end of the nursing unit Resident #335 resided on. After surveyor intervention, STNA #922 entered Resident #335's room to provide incontinence care. STNA #922 stated he arrived for work at 3:00 P.M., had been answering resident call lights and had not provided incontinence care for Resident #335. RN #837 walked in Resident #335's room and stated she did not tell STNA #922 that Resident #335 needed his incontinence brief changed. RN #837 stated she told STNA #820 who left at 3:00 P.M. Resident #335 needed his incontinence brief changed. RN #837 assisted STNA #922 to provide incontinence care for Resident #335. Observation revealed Resident #335's incontinence brief was soaked with urine and a very large diarrhea bowel movement and no dressing was observed when the incontinence brief was removed. Further observation revealed Resident #335's buttocks and sacral area were dark red and purple areas were noted along with a large black area on the left buttock. The large black area measured approximately three inches by one inch. The dark red and purple areas extended across both buttocks and did not blanche in the middle. Large open areas with red wound beds and reddish drainage approximately three inches in diameter were noted across bilateral buttocks, the coccyx area was a dark purple black in color and did not blanche. Further observation revealed a small dark area on right buttock sacral area, the left leg upper thigh had a small open red area with a dark center. These observations were confirmed by RN #837. RN #837 used wound cleanser, applied Triad cream, xeroform, and a foam border dressing to the sacral area. After surveyor intervention RN #837 and STNA #922 cleaned additional diarrhea from the crease of Resident #335's buttocks which was missed when incontinence care was completed. Additional observations revealed Resident #335's upper thigh was red in area of scrotum, scrotum was red and irritated looking, right upper thigh wound revealed a dark wound bed and was approximately a quarter size, red around edges. Resident #335 did not have a LAL mattress on his bed. Additional observations were confirmed by RN #837. Interview on 03/13/23 at 5:13 P.M. with the DON revealed she did Resident #335's initial wound assessment. The DON indicated there was one spot that looked like it had MASD surrounding it, and was not macerated, open and bleeding. The DON stated there was some redness and the wound had a lot of slough, slough was pretty yellow, and a little darkened. The DON stated the wound possibly had a small amount of necrotic (dead) tissue. The DON stated she noted Resident #335 had excoriation on the inside of his thighs and scrotum. The DON indicated Resident #335 was admitted from the hospital on [DATE]. The DON stated she did not measure the wounds and she should have. The DON confirmed Resident #335 was on a pressure reducing mattress and not a LAL mattress. Interview on 03/14/23 at 6:54 A.M. with State Tested Nursing Assistant (STNA) #900 revealed she saw Resident #335's bottom when he was admitted . STNA #900 stated Resident #335 had a sacral dressing and she could not see under the dressing, but the wounds around the dressing were present on admission. Observation on 03/14/23 at 10:50 A.M. of Resident #335 with Wound Nurse Practitioner (WNP) #925 and the Director of Nursing (DON) revealed this was her first visit for Resident #335. Observation revealed Resident #335 was lying on his back in bed and his incontinence brief was soaked with urine and a very large liquid bowel movement which was brownish green in color. Resident #335's urine and bowel movement leaked out of the incontinence brief and was noted on the sheets and blanket. Resident #335 did not have a dressing on his sacral area. Resident #335 had a left ischium wound which was measured at a length of 1.5 cm, width of 1.8 cm and depth was unable to be determined. A sacrum wound measured a length of 11.5 cm and a width of 11.5 cm and depth was unable to be determined due to it was unstageable. The DON stated she did the initial assessment when Resident #335 was admitted to the facility, but Resident #335 had a dressing on and she did not pull the dressing all the way down to do a full assessment. The DON stated she did not know if all the wounds were present when Resident #335 was admitted to the facility. The DON stated she changed Resident #335's dressing this morning and he had a dressing on at that time. Further observation revealed Resident #335 had an unstageable pressure ulcer to the right ischium and measured a length of 3.5 cm, width of 2.5 cm and depth was unable to be determined. The DON stated Resident #335's wound changed since she saw it when he was admitted , and she thinks the top part deteriorated. The DON stated when he was admitted she just pushed the dressing down a little bit but did not see the entire wound. The DON stated another nurse started the assessment and she finished it. The DON indicated she did not measure Resident #335's wounds upon admission, used the hospital paperwork as a guide when she filled out the initial assessment. Interview on 03/14/23 at 2:33 P.M. with Licensed Practical Nurse (LPN) #884 revealed he admitted Resident #335. LPN #884 could not remember details about Resident #335's wounds but remembered the wounds were dark in spots, had some redness, purple areas and the wounds were not bleeding. LPN #884 stated he started, and the DON finished up the admission assessment. LPN #884 stated Resident #335 was weak and sore and needed a lot of help with bed mobility and could not do it on his own. Interview on 03/15/23 at 8:42 A.M. and 11:00 A.M. and 4:48 P.M. revealed Resident #335 was lying on his back in bed. There was no observation of staff turning and repositioning or encouraging Resident #335 to turn and reposition. Observations on 03/16/23 at 9:13 AM and 10:50 A.M. revealed Resident #335 was lying on back. No observations of staff turning and repositioning Resident #335. Interview on 03/16/23 at 10:59 A.M. with STNA #960 revealed she had not provided incontinence care for Resident #335 or turned and repositioned him. STNA #960 stated she started at the back of her nursing unit and worked her way forward and was going in Resident #335's room in the next few minutes. STNA #960 stated another aide told her Resident #335 was changed around 8:00 A.M. 3. Review of Resident #52's medical record revealed he was admitted on [DATE] with diagnoses including hemiplegia, acute respiratory failure and cerebral infarction. Review of Resident #52's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he exhibited a memory problem. Review of Resident #52's Wound Evaluation form dated 03/14/23 indicated he had a sacrum stage three (full thickness skin loss, involving damage or death of subcutaneous tissue that may extend down to, but not through, underlying tissues and muscles) pressure wound measuring 4.5 cm length by 4.0 cm depth by at least 0.5 cm depth with 60% (percent) granulation tissue, 20% necrotic tissue (slough). The treatments included to cleanse the wound with wound cleaner, apply anasept gel (antibiotic) then apply dermablue (antimicrobial) or hydrofera blue (antimicrobial), cover with a large sacral foam dressing and change three times a week and as needed. Position side to side only. Observation on 03/16/23 at 7:00 A.M. revealed Resident #52 was lying on his back with his arms positioned at his sides and he was lying on an air mattress. He was not alert and oriented, had a tracheostomy tube and a feeding tube with feeding solution infusing at 75 ml (milliliters) per hour at the time of the observation. Interview on 03/16/23 at 7:30 A.M. with Licensed Practical Nurse (LPN) #858 confirmed Resident #52 was positioned on his back when he should be positioned side to side only to prevent further deterioration of his pressure ulcer wound. Interview on 03/16/23 at 7:34 A.M. with LPN Minimum Data Set (MDS) Coordinator #907 revealed Resident #52's care plans did not include the intervention to only position the resident from side to side and not on his back. Interview on 03/16/23 at 9:10 A.M. with the Director of Nursing (DON) confirmed Resident #52's wound documentation indicating he should be positioned side to side only and she was unsure why it was not care planned as a wound/skin intervention in his medical record. Review of the facility policy titled Pressure Ulcer Prevention and Assessment dated, 12/17/13, included it was the policy of the facility to prevent the development of pressure ulcers to the greatest extent possible and as allowed by the resident's compliance, cognition and or physical function. For a person in bed change position at least every two hours or more frequently as needed, determine if the resident needed a special mattress, raise the head of the bed as little and for as short a time as possible and only as necessary for meals, treatments and medical necessity. Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of skin irritation or breakdown. Immediately report any signs of a developing pressure ulcer to the supervisor and physician. Place resident on a minimum of every two hour check and change. Impaired mobility, decreased functional ability, cognitive impairment, exposure of skin to urinary and fecal incontinence are additional clinical condition that indicate a resident was at risk for pressure ulcers. This deficiency represents noncompliance investigated under Complaint Number OH00140816 and Complaint Number OH00140473.