**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to: a.) prevent an avoidable facility-acquired Stage III (full thickness tissue loss) pressure ulcer to the sacrum for a resident assessed to be at mild risk for developing a pressure ulcer, b.) re-assess the resident for pressure ulcer risk upon development of the wound, c.) appropriately assess including a suspected stage of the pressure ulcer in a timely manner to prevent worsening, d.) ensure the accountability for off-loading the sacral pressure ulcer in accordance with the Wound Consultant recommendations, e.) ensure all staff that provide direct care to the resident had knowledge of the presence of the pressure ulcer to prevent the wound from worsening, f.) a comprehensive care plan was updated upon the development of the wound, g.) perform wound care to the pressure ulcer in accordance with professional standards of nursing practice, and h.) ensure the accountability and use of pressure-relieving suspension heel booties in accordance with a physician's order to prevent skin breakdown. This deficient practice was identified for 1 of 3 residents reviewed with skin breakdown, Resident #12. The evidence was as follows: 1. On 2/17/21 at 11:17 AM, the surveyor observed Resident #12 in a private room sitting upright in a high-back wheelchair with a mechanical lift pad under his/her body. There was a soft gel cushion to the seat of the resident's wheelchair. The resident was wearing bilateral geri-sleeves (an arm sock used to prevent skin tears) to the arms, and a pair of white socks and black velcro shoes. The surveyor further observed a pair of pressure-relieving suspension heel booties sitting on top of the resident's low air loss mattress on the bed. The surveyor attempted to interview the resident but the resident did not verbally respond to the surveyor. At 1:30 PM, the surveyor observed Resident #12 in his/her private room in the high back wheelchair in the same upright position sitting on top of a mechanical lift pad and gel seat cushion. The resident was still wearing the black velcro shoes and the pressure-relieving suspension heel booties were positioned on top of the resident's air mattress on the bed. On 2/22/21 at 10:03 AM, the surveyor observed Resident #12 sitting upright in the high back wheelchair on the gel cushion. The resident was sitting on top of a mechanical lift pad. The surveyor observed that the resident was wearing the same black velcro shoes and the heel booties were sitting on a cabinet in his/her room. The surveyor reviewed the medical record for Resident #12. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 7/22/20 reflected that the resident was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease and arthritis. The MDS assessment further revealed that the resident was rarely or never understood and a Brief Interview for Mental Status (BIMS) score could not be obtained, so staff assessed the resident's cognitive status which indicated that the resident had a short- and long- term memory problem and a severely impaired decision-making capacity. The resident was assessed to have no behaviors that impact care, and that he/she was dependent on staff for all activities of daily living (ADL's) and was an extensive two person physical assist for bed mobility and transfers. The MDS further included that the resident was always incontinent (loss of control) of bowel and bladder, and was at risk for developing a pressure ulcer but had no pressure ulcers on admission to the facility. A review of the resident's individualized comprehensive Care Plan Report with a print date of 2/23/21 at 9:12 AM reflected that the resident was at risk for skin impairment due to limited mobility. The care plan reflected that the resident had a history of a bluish discoloration to the right lateral foot on 9/24/20, but no current open wounds. A review of the goals reflected that the resident will remain free from skin breakdown through the next review period but there was no date of when the next review period was. Undated interventions included to provide a protein supplement Prostat 30 milliliters twice a day as ordered, utilize pillows, pads or wedges to avoid pressure points, assist with routine repositioning, cleanse skin well after incontinence episodes and apply skin protectant if appropriate and provide heel pressure relief as appropriate. The care plan further reflected the use of a prima-shearless mattress [a mattress that reduces friction rub] but it did not address a low air loss mattress. The care plan also indicated that the resident was always incontinent and to turn and reposition the resident to prevent skin breakdown. The goal reflected that the resident's Skin will remain intact during the next 90 days but there was no date for the goal period. The surveyor attempted to review the resident's Braden Scale Risk Assessment, an assessment tool used to determine risk of developing a pressure ulcer, completed upon admission to the facility, but it was not available in the resident's electronic medical record or the hybrid medical chart. The surveyor attempted to review any subsequent Braden Scale Risk Assessments, but there were none accessible in both the resident's electronic medical record or the hybrid medical chart. A review of a laboratory report dated prior to admission collected on 6/16/20, reflected that Resident #12 had a slightly low albumin (a protein produced by the liver and used as a factor to assess nutritional status) level of 3.4 grams/deciliter (g/dL) (normal albumin is 3.5-5.2 g/dL), and a slightly low total protein level of 6.2 g/dL (normal protein is 6.4-8.3g/dL). A review of the February 2021 Physician's Order Sheet (POS) reflected a physician's order (PO) dated 7/16/20 to perform a skin check twice a week during the evening 3-11 PM shift, and a PO dated 7/17/20 to apply Z-guard paste (moisture barrier cream) to buttocks every shift. In addition there was a PO dated 9/11/2020 to administer a protein supplement, Prostat Sugar-Free AWC [Advanced Wound Care] 30 milliliters (mL) by mouth twice a day at 9 AM and 5 PM daily. A review of the electronic Medication Administration Record (eMAR) for December 2020 and January 2021 reflected the corresponding PO for the Prostat dated 9/11/20. The order reflected that the protein supplement was ordered due to Other Skin Changes and was signed to reflect that the resident was receiving the Prostat 30 mL twice a day without refusals. A review of the most recent quarterly MDS assessment dated [DATE] reflected that the resident had no current skin breakdown or pressure ulcers. A review of the Clinical Notes Report dated 1/28/21 at 11:37 PM and written by a Registered Nurse (RN) reflected that the resident was received in bed awake, alert and confused and unable to verbalize needs .During PM [evening] care CNA called the writer to check on resident's buttocks, immediately went to check . Upon assessment noted an open area/wound to left buttock measuring 1.5 centimeters (cm) x 3 cm, no active bleeding noted, no signs of pain or distress . The note reflected that the Attending Physician/Medical Doctor (MD) was made aware and ordered Medihoney gel (a debriding agent) to the left buttock wound after cleansing with with normal saline and covering it with an optifoam dressing daily and as needed. The note also indicated that the MD ordered a wound consult and the family was notified. The note further included that the ordered treatment was rendered and resident was turned and repositioned to offload pressure. The assessment did not reflect evidence of a measured/estimated measured wound depth or why a measurement for a wound depth could not be obtained. The note further did not document an assessment for a suspected stage of the pressure ulcer in accordance with professional standards of nursing practice. A review of the February 2021 POS reflected the PO dated 1/28/21 at 11:03 PM to Cleanse the left buttock open area/wound with normal saline, pat dry, apply Medihoney and cover with optifoam dressing daily and PRN [as needed] until healed. The PO reflected that the treatment was to be done during the day shift, 7AM -3 PM. A review of the January 2021 eTAR reflected that a nurse signed that Resident #12 had a twice weekly skin check performed on the evening shift on 1/27/21, the day before the wound was identified. There was no documented evidence for the findings of the complete skin assessment signed as conducted on 1/27/21 in the eTAR or in the Clinical Notes Report. There was no Clinical Notes Report Nursing Notes dated 1/27/21. In addition, the January 2021 eTAR reflected that the nurses signed each shift (day, evening and night shift) that the Z-guard moisture barrier paste was getting applied to the buttocks, including each day prior to the identification of the wound on 1/28/21. There was no Clinical Notes Report/Nursing Notes documentation from 1/26/21 at 8:51 PM until 1/28/21 at 11:37 PM when the wound was identified. Subsequently there was no clinical nursing notes dated 1/29/21 written the day shift nurse after the wound was identified, but during the evening 3-11 PM shift at 9:19 PM, the resident was placed on a low air loss mattress. There was no further documented nursing notes written on 1/30/21 by the day shift or evening shift to indicate a wound assessment including measurements, interventions in place, if the resident tolerated the scheduled wound treatment, or if the resident got out of bed to the wheelchair and if so, how long the resident remained out of bed. A review of a Nutrition Progress Note dated 1/29/21 at 2:50 PM, the day after the left buttock wound was identified, reflected that the Registered Dietician (RD) acknowledged that the resident presented with a left buttock wound and was currently already receiving a protein supplement twice a day to preserve skin integrity. The note indicated that the Prostat supplement should continue and that the resident will follow up with a Wound Consultant. The Clinical Notes for nursing dated 1/29/21 the resident was now on a low-air loss mattress. The surveyor reviewed the Clinical Notes Report for January 2021 prior to the development of the left buttock wound. The clinical nursing notes reflected that Resident #12 had a good appetite specifically on the following dates and times: 1/1/21 at 10:31 PM, 1/5/21 at 9:23 PM, 1/9/21 at 12:02 PM consumed 90% of meal, 1/10/21 at 2:41 PM consumed 90% of meal, 1/10/21 at 10:30 PM, 1/11/21 at 8:46 PM, 1/15/21 at 9:33 PM, 1/18/21 at 8:51 PM, 1/23/21 at 8:53 PM. A review of the Nurse Practitioner's (NP) Progress Notes dated 1/11/21 and 1/20/21 reflected that the resident's appetite is good and the laboratory report on 6/16/20 were Unremarkable. A review of the Initial Wound Consult report dated 2/4/21, seven days after the wound was identified on 1/28/21, reflected that the resident presented with a Stage III (full thickness tissue loss) pressure ulcer to the sacrum that measured 5 cm x 6 cm x 0.2 cm (this was an increase in size from measurements of 1.5 cm x 3 cm when the wound was identified on 1/28/21). The consult report further reflected that the wound was covered in 40% moist yellow slough (dead tissue) with 60% granulating (healthy) tissue. The Wound Consultant (WC) reflected that the subcutaneous and dermis tissue layers of the skin required debridement (removing the dead tissue from the wound to promote wound healing) and the MD performed a debridement procedure which had a minimal amount of bleeding .controlled with pressure. After debridement of the wound, it measured an expected increase in depth from 0.2 cm to 0.4 cm. The resident tolerated the procedure well. The Consult Report further included that the resident was on a low air loss mattress and had a foam seat cushion. Recommendations included to apply Medihoney gel to the wound and cover it with a (silicone) foam adhesive dressing daily. Offloading recommendations included, Recommend a Roho wheelchair cushion, with seat lifts or position shifting in chair every 15 minutes . Recommend limiting continuous time spent sitting to less than 2-3 hours per session. The WC indicated that the Plan of Care was discussed with facility staff. A review of the February 2021 POS did not reflect evidence for the WC recommendation to do a seat lift or position shifting every 15 minutes while in chair, nor did it address to limit the time spent sitting to less than 2-3 hours per session. A review of the eTAR or eMAR for January 2021 or February 2021 did not reflect documented evidence for the PO or accountability for the offloading recommendations in accordance with the WC report. A review of the resident's individualized comprehensive Plan of Care, did not address the resident's new stage III pressure ulcer to the sacrum, the need to limit out of bed sitting to 2-3 hours per session, or shifting positions while in the chair every 15 minutes in accordance with the WC recommendations. Further, there was no documentation in the Clinical Notes Report for February 2021 that addressed a rationale as to why the WC recommendations for offloading were not being followed. A review of the subsequent Wound Consult Report dated 2/11/21 included that the resident continues to present with a Stage III pressure ulcer to the sacrum that has not yet healed. The report indicated that the wound had decreased in size to 4 cm x 4 cm x 0.2 cm with a moderate amount of serous (clear) drainage noted without odor and indicated that the wound is improving .decreased in size with 20% slough and 80% granulation tissue. The resident's wound was debrided using a blade which resulted in a minimal amount of bleeding controlled with pressure. The post-debridement measurements were 4 cm x 4 cm x 0.4 cm. The Plan for treatment and off-loading were written and remained the same from the Initial Wound Consult Report dated 2/4/21. In addition to the sacral ulcer, the surveyor reviewed the following physician's orders related to pressure relief for the resident's bilateral feet and heels: A review of the electronic February 2021 Physician's Order Sheet (POS) reflected a physician's order (PO) dated 9/3/20 for No Shoes daily with accountability documentation every shift (day, evening, and night shift). In addition there was a PO dated 10/23/2020 to Check heel booties to be worn at a frequency of: Continuous. A review of the December 2020, January 2021, and February 2021 electronic Treatment Administration Records (eTAR) reflected that the nurses were signing every shift (day, evening and night shift) that the resident was not wearing shoes. The eTAR's did not reflect the PO dated 10/23/20 for the use of the continuous heel booties, no evidence of accountability for the heel booties. The eTAR for February 2021 reflected that the nurse signed that the resident was not wearing shoes on 2/17/21 and 2/22/21 during the day shift, but this did not correspond with what the surveyor observed on those dates. A review of the December 2020, January 2021, and February 2021 electronic Medication Administration Records (eMAR) did not reflect evidence for the physician's order dated 10/23/20 for the heel booties to be worn continuously, and therefore there was no accountability for the implementation of the order. A review of the resident's Clinical Notes Report from 11/1/20 to 2/22/21 did not reflect documented evidence for the use of the pressure relieving heel booties, nor documentation as to why the resident was observed to be wearing shoes and not the heel booties on 2/17/21 and 2/22/21, in direct contradiction to the physician's order. On 2/22/21 and 2/23/21, surveyor continued to make observations and interview staff regarding the resident's facility-acquired stage III pressure ulcer, and the orders for the heel booties and no shoes. On 2/22/21 at 10:14 AM, the surveyor interviewed the Certified Nursing Aide (CNA) assigned to care for Resident #12. The CNA stated that the resident was non-verbal and was total care. The CNA clarified that total care meant that he/she was dependent on staff for all activities of daily living including but not limited to: feeding, toileting, mobility, and transfers. The surveyor asked the CNA if Resident #12 was able to follow commands such as requesting to turn or assisting in the turning process, and the CNA stated that the resident cannot follow commands. The CNA stated that today she was assigned six residents on her assignment but other days she could have up to 12 residents on her shift. The surveyor asked the CNA about the resident's toileting needs and the CNA stated that he/she was always incontinent of bowel and bladder and she put a moisture barrier cream on the resident's perineal area with each incontinent episode to protect the skin from breakdown. She stated that she will try to check on the resident's continent status three times a day throughout the course of her shift. She stated that each time she would check on the resident he/she was usually wet. She stated that the resident only required a one person physical assist with hygiene care, but stated that some CNA's may be more comfortable having two staff to assist with cleaning the resident. The surveyor asked the CNA about the condition of the resident's skin, and the CNA stated his/her Skin is good. The surveyor asked what she meant by good and the CNA clarified that the resident's skin was clean and intact She stated that the resident used to have a wound on the left buttock a long time ago but it had since healed. The CNA confirmed that there was no dressings on the resident's sacrum or buttocks when she performed morning care on the resident at approximately 8:30 AM this morning. The CNA continued to state the resident usually gets out of bed to the wheelchair by 9 AM every day, and that she puts Resident #12 back to bed by 2 PM at the end of her shift. The surveyor asked if there was any maximum length of time that the resident was allowed to be out of bed into the chair for, and the CNA stated that there was no maximum limit to how long the resident was allowed to remain out of bed. The CNA could not speak to repositioning the resident in the wheelchair every 15 minutes, but stated that the resident had a gel seat cushion on the wheelchair. She continued that the resident had fragile skin so he/she wore geri sleeves to the arms and legs to prevent skin tears. She stated that there was nothing else she had to do to protect the residents skin except applying the moisture barrier cream with incontinent episodes, applying the geri-sleeves, and making sure the resident was sitting on the gel cushion in the chair. The surveyor asked if she received a verbal or written report from the nurse this morning, and the CNA stated that she regularly cared for Resident #12 and that the two nurses that were working today were on their second day of orientation so she did not get any report because the nurses were just learning about all the residents. At 10:23 AM, the surveyor approached two nurses who were working alongside the Director of Nursing (DON). The DON stated that she was orienting both nurses to the floor and it was approximately their second day on the job. She stated that the nurses wouldn't be able to speak much on the past history of the residents, but that she would be able to. The DON confirmed that there was also currently no Unit Manager (UM) as the UM had left approximately two weeks ago and they had not yet replaced the position. The surveyor interviewed the DON at that time who stated that the facility had no residents in-house with facility-acquired pressure ulcers. The surveyor asked if Resident #12 had a pressure ulcer, and the DON stated that the resident was admitted with it. The DON elaborated that all of the residents that currently had wounds were admitted to the facility with those wounds. The DON stated that she couldn't speak further to the pressure ulcer but that if the surveyor had any other questions she would look into it. On the same day 2/22/21 at approximately 12:05 PM, the surveyor observed Resident #12 out of bed sitting upright in the high back wheelchair sitting on a gel seat cushion. The resident was wearing black velcro shoes. (This reflects a period of three hours of continuous sitting in which the resident was in his/her wheelchair according to the interview with CNA and surveyor observation). On the next day on 2/23/21 at 09:10 AM, the surveyor observed resident sitting upright in a high back wheelchair sitting on a gel foam cushion. The resident was wearing the same black velcro shoes and not wearing heal booties. The resident's legs were slightly reclined in the chair. At 9:26 AM, the Licensed Nursing Home Administrator (LNHA) stated to the surveyor that the DON was currently out on leave and was not available for an interview. The surveyor asked if Resident #12 had a facility acquired pressure ulcer, and the LNHA was unable to speak to it. She stated that she would have to get back to the surveyor on that. On 2/23/21 at 10:00 AM, the surveyor interviewed the resident's same assigned CNA. The CNA confirmed to the surveyor that the resident was previously seen by the Wound Consultant every Thursday but now that the wound to the buttock had healed, there were no other wounds. The surveyor sought clarification with the CNA who stated there were no wound dressings anywhere on the resident's body. She stated that she just puts a Zinc-based moisture barrier cream to the resident's sacrum and that she had applied it this morning, and that's how she knew there was no dressing or skin openings to the buttocks or sacrum. The CNA stated that she does not need to apply the heel booties as they were only intended for when the resident was in bed at night. She stated that the heel booties were for bedtime because the resident used to have something on the right foot but that it was gone now. She stated that she always applied the black velcro shoes to the resident when the resident gets out of bed. The CNA stated that she was not aware of any physician orders to not apply shoes and for the resident to only wear suspension heel booties. The CNA stated that the resident got out of bed to the chair at around 8:30 AM this morning, and that she planned to put the resident back to bed around 1 PM after her lunch break. The CNA confirmed that the resident had no behaviors of refusing care. At 10:19 AM, the surveyor interviewed the Registered Dietician (RD) who stated that she worked part time at the facility approximately three days a week. The RD stated that the resident was on a pureed diet and was dependent on staff for feeding assistance. She stated that the resident was on a protein supplement twice a day since admission to the facility in July 2020 and that as far as she knew, the resident never refused the protein supplements. She stated that she added a health shake with meals when the resident had a slight decrease in weight that was not significant. The surveyor asked about the resident's nutritional status and she stated that the resident had a good appetite and usually ate 75%-100% of all his/her meals. She stated that she didn't know about any recent nutritional labs taken, but confimed she didn't recommend any from previous quarterly visits with the resident, because nutritionally she seemed good. She stated that when the resident developed the stage III pressure ulcer, she saw the resident on 2/6/21 again and made recommendations for Vitamin C, Zinc, and a multivitamin with minerals to aid in wound healing. The RD and the surveyor reviewed the resident's eMAR's together with the Prostat supplement, and the RD confirmed there was no resident refusals. She stated that she could not speak to how the resident developed a stage III pressure ulcer from a nutritional standpoint because there were no significant deficits or changes. At 10:39 AM, the surveyor requested to perform a skin check with the CNA and the resident's assigned Licensed Practical Nurse (LPN). At 10:49 AM, after Resident #12 was transferred back to bed using a mechanical lift, the CNA removed the resident's black velcro shoes and socks and the surveyor observed the that the resident's bilateral heels and feet were clean with no skin breakdown. The CNA removed the incontinent brief and stated that the resident had a urinary incontinence episode so she would change the resident's brief. As that CNA removed the resident's incontinent brief there was a large foam dressing secured to the resident's sacral area. The dressing was not dated. The CNA stated that she had no idea how the dressing got there and that Resident #12 was on her assignment both yesterday and over this past weekend and the resident never had a foam dressing on the sacrum. The CNA stated that the wound might have reopened. As the CNA removed the undated foam dressing to the resident's sacrum, the LPN entered the room. The surveyor observed under the dressing was a very thick film of white paste covering the entire sacral and upper buttock area under where the dressing was located, but the cream was not anywhere else on the resident's perineal area. The surveyor looked at the resident's left buttock area and did not see any evidence of a gold colored residue or Medihoney on or around the wound. The surveyor was able to visualize the left buttock wound but the base of the wound was covered in the white moisture barrier cream. The CNA stated that she would clean the moisture barrier cream off the resident and she proceeded to cleanse the area with soapy water. The surveyor and the LPN looked at the resident's wound and the old dressing together. The LPN stated that she had applied the dressing at approximately 7:45 AM this morning and did not date the dressing because she did not have a pen on her at the time. The surveyor asked what treatment she put on the wound and she stated that she applied Medihoney and that it was gold in color. The surveyor asked if she saw any remnants of any gold colored Medihoney on the resident's wound which was covered in the white paste, and she stated that she did not. The surveyor and the LPN looked at the old dressing. The old dressing had a scant amount of pink tinged drainage on it and there was no visual evidence of Medihoney on the dressing. The surveyor asked how she applied the Medihoney this morning and she stated that she applied a small dab to the dressing itself and that she thought the pink tinged drainage reflected where she had applied the Medihoney. The surveyor took a picture of the old dressing in the presence of the CNA and the LPN. The LPN stated that she applied the Medihoney but couldn't speak to why the base of the wound had a white barrier cream instead of a gold colored gel. The LPN and the surveyor reviewed the eTAR for February 2021 together. The LPN confirmed she had not yet signed for the application of the dressing for the Medihoney treatment that she had performed at 7:45 AM. She stated that she was supposed to sign for the treatment in the eTAR after it was done. At that time, the CNA confirmed that the resident had a wound to left buttock, but continued to state that she was surprised that it was there. She stated that if she had seen the wound she would let the LPN know right away, and the LPN would call the doctor for a treatment. She stated in the presence of the LPN a second time that she had the resident assigned to her over the past weekend and during incontinent episodes the resident never had a dressing on his/her buttocks or sacrum. She could not speak to how the presence of wounds gets communicated to her other than through verbal report. She stated that she had electronic access to the resident's care plan, but couldn't speak to what it said about the resident's current skin status. At approximately 11:00 AM, the surveyor observed the LPN perform a wound treatment to the resident's left buttock stage III pressure ulcer. The LPN stated that the wound was a stage II pressure ulcer (partial thickness tissue loss) and that it was acquired within the facility and not on admission. She stated that it had been there for a few weeks and the WC comes weekly to evaluate it. She stated that she would assess the wound to be healing, pink and granulating. The surveyor observed the resident's wound after it was cleaned from the white paste, and observed that the stage III pressure ulcer was about the size of a dime and was pink with 100% granulation tissue. There was no evidence of slough on the wound bed. The LPN performed the wound dressing change in accordance with physician's order in the presence of the surveyor, by cleansing the wound with Normal Saline Solution (NSS) and applying a nickel-sized amount of gold-colored Medihoney gel onto a tongue blade and used the tongue blade to apply the treatment to the resident's wound. The LPN then applied a small foam dressing to the wound and dated the dressing using pen from her pocket. The CNA applied Z-guard barrier cream around the resident's buttocks and applied a new incontinent brief. At 11:15 AM, the surveyor continued to interview the LPN. The LPN stated that the resident gets out of bed to the wheelchair and was allowed to be out of bed for a maximum of four hours to prevent more pressure to the wound. She stated that the CNA's turn and reposition the resident every two hours and they were supposed to sign for it. (This did not correspond with the WC recommendations for 15 minute repositioning while in the chair or a maximum continuous sitting of 2-3 hours). She stated that it was important for the resident to off-load the area and that he/she had an air mattress and a gel cushion to sit on when in the chair that provided pressure relief. The LPN acknowledged that there was a physician's order for no shoes in the resident's physician's order. She had not yet signed in the accountability log. She stated that she doesn't apply shoes and if she were to see them, she would take them off the resident. She stated that the order was there because the resident had once had a skin condition to the right foot. The LPN acknowledged the order that indicated for continuous heel booties. She could not speak to if it was done or if it was still needed. She stated that the resident's feet and heels had intact skin. On 2/23/21 at 11:24 AM and 12:30 PM, the surveyor interviewed the LPN and an Registered Nurse to see if there was a Braden Scale Risk Assessment for the resident. The LPN and RN were unable to find one within the electronic medical record or the hybrid medical chart for Resident #12 when looking together through both. The RN showed the surveyor another chart that had a Braden Scale but confirmed that was for another resident. Neither the LPN nor the RN could speak to the resident's risk for developing a pressure ulcer. They both stated that usually the UM did the assessments, stating that they thought that it was the UM because they didn't have to do them. They both stated that the UM and the MDS Coordinator left two weeks ago and was no longer employed by the facility and they did not replace them yet. They also both stated that they are not involved in the care plans for the resident, only the UM and MDS Coordinator did that because the administration wanted the care plans to be written a certain way. They stated that they were never told they had to do the care plans since they had left. They could not speak to who else may be overseeing the care plans. On 2/23/21 at 12:10 PM, the surveyor observed the CNA providing one-to-one assistance with feeding Resident #12 in his/her private room while in bed. The surveyor observed the re[TRUNCATED]