**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a confidential interview it was indicated, the biggest concern related to Resident C's care at the facility, was how bad her foot and legs got. They weren't that bad in the hospital, then all of the sudden she got sent back to the hospital with black feet. She did originally have an ulcer on the bottom of her foot, but when she got back to the hospital, they were gangrene and black and looked like they were rotted off. Resident C was supposed to have a follow up doctor's appointment on 3/28/22 but the DON didn't do anything about it. On 4/13/22 at 3:58 p.m., Resident C's medical record was reviewed. She was admitted to the facility on [DATE] after a 4 day hospital stay where she was treated primarily for a foot fracture sustained during a fall at home and received secondary treatment for burns sustained in a previous smoking accident. A hospital discharge summary for the hospitalization prior to admission was dated 2/28/22. The discharge summary included an updated medication and treatment regime that did not indicate any treatments to her feet. The discharge summary indicated Resident C had a pre-scheduled orthopedic follow up appointment for 3/28/22. The discharge summary indicated Resident C had sustained a closed, nondisplaced fracture of the 5th metatarsal bone of the left foot with delayed healing. Multiple skin burns, skin tears, and skin wounds were noted with instructions to clean the wounds two times a day and apply santyl. As for the left foot fracture instructions were given to administer gabapentin 100 mg at bedtime and wear a surgical shoe when out of bed. A physical exam was conducted upon her discharge and her skin was noted to have a large healing burn on her back and neck and left lower extremities with healing areas. The discharge summary did not indicate Resident C had any gangrene or necrotic tissue. Resident C's admission orders, (initiated upon her admission on [DATE]) were reviewed. There were no admission orders for treatment to her burns and skin wounds. An admission nursing progress note 2/28/22 at 1:58 p.m., Resident C admitted with diagnoses of closed non-displaced fracture of 5th metatarsal bone of left foot with delayed healing, weakness, history of CVA (stroke), burn, severe protein- calorie malnutrition and vitamin D deficiency. Resident C was alert with periods of confusion and disorientation, but able to ambulate with boot on left foot. Her skin was noted to have multiple areas of impairment including sacrum, coccyx, left foot and toes, and left hip. The admission progress note lacked documentation of the description of the wound areas and did not indicate any area of her body with gangrene or necrotic tissue. A comprehensive nursing admission assessment dated [DATE] at 1:58 p.m. indicated the following wound locations, description and measurements: a. Wound 4 was a burn, located on her face that measured 4 centimeters (cm) long, by 2 cm wide, by 0.5 cm deep b. Wound 26 was an unstageable pressure ulcer, located on her left hip that measured 5 cm long by 2.5 cm wide, and 0 cm depth. c. Wound 52 was an unstageable pressure ulcer, located on her left toes that measured 1.5 cm long, by 2.0 cm wide, and 0.1 cm deep. d. Wound 50 was an unstageable pressure ulcer, located on her left heel that measured 3.5 cm long, by 3.0 cm wide, and 0 cm depth. e. Wound 53 was a suspected deep tissue injury, located on her sacrum that measured 2 cm long, by 1.5 cm wide, by 0 cm depth. f. Wound 23 was a stage 4 pressure ulcer, located on her coccyx that measured 3 cm long, by 2 cm wide, by 0.3 cm deep. The record lacked documentation that Resident C had been referred to, and/or evaluated by SWAT, (skin and wound team). Resident C was seen via a tele-health video conference call on 3/1/22 at 10:12 a.m. The tele-health progress note indicated Resident C had pain in her foot, that was constant and aching. The note did not indicate which foot, and upon a physical exam, the note did not indicate Resident C's feet had been examined. No new orders were given, and the treatment plan for the Resident's pain was to continue Norco 5/325 mg as needed and follow up with orthopedics (ortho) as scheduled. Resident C's baseline care plan, dated 3/1/22, lacked documentation of the above noted skin integrity concerns Another tele-health progress note, dated 3/2/22 at 1:33 p.m., incorrectly documented Resident C as a male. Treatments for Resident C's multiple wounds which included but were not limited to her left foot and toes were not initiated until 3/4/22, 4 days after her admission. On 3/4/22 at 4:16 p.m., an acute tele-health video visit was conducted for the chief complaint of pain. The progress note indicated, .dry gangrene of the LE [left extremity] . Patient appears anxious and uncomfortable during visit, she states she is in severe pain. Pain is 10/10 located at her lower extremities, she has a difficult time describing the pain however per nurse report it has been excruciating and inhibiting her from normal functioning/obtaining adequate sleep. She appears ill and very cachectic. She denies other symptoms however her pain level appears to be inhibiting her from being able to accurately answer questions . severe pain 2/2 dry gangrenous skin lesions New orders were given to increase her pain medication by adding Oxycodone 10 mg every 6 hours. On 3/11/22 Resident C was placed on Hospice. An admission hospice narrative 3/11/22 at 12:00 p.m., indicated .patient came to facility with necrotic extremity although as noted above, the admission documentation lacked any description of necrotic or gangrenous tissue. A nursing progress note, dated 3/31/22 at 12:14 p.m., indicated Resident C had been sent to the ED (emergency department) due to a decline A hospital admission note, dated 3/31/22, indicated, [Resident C] presents to ED via EMS [emergency medical staff] from ECF [extended care facility] for further evaluation of necrotic left lower extremity. Per EMS, ECF stated necrosis has been getting progressively worse and started to drain upon arrival . LLE with gangrene to left knee from plantar aspect of foot, concerns for wet gangrene . she has extensive dry gangrene of the left lower leg extremity involving nearly the complete lower leg. She has evidence of wet gangrene on the distal left thigh most notably on the posterior aspect . patient was deemed a poor surgical candidate as CTA (Computed tomography angiography) demonstrates occlusion of the bilateral iliac as well as superficial femoral on the left Further the hospital record indicated, .patient present to the hospital with acute mental status change and LLE gangrene. Patient has been in a nursing facility and has a previous history of stroke and residual left side weakness. Patient was seen by ortho before for previous left foot fracture treated non-operatively. She had multiple scabs on her foot at that time. She has been in an ECF for the past month. She presents today with gangrenous extremity up to the knee During an interview on 4/13/22 at 3:10 p.m., the Regional Director of Clinical Operations, (RDO) indicated, Resident C had not been referred to SWAT because of staffing issues the facility had in March. When the RDO was informed of the limited and inaccurate documentation of Resident C's wounds (as compared to the hospital records which noted increased in size and severity from a couple of scabs on her left toe, to full wet/dry gangrene from her foot to her ankle), the RDO indicated the documentation was lacking and it was very important to capture the full extent of a resident's wound upon admission to better serve the resident. During an interview on 4/13/22 at 3:17 p.m., the Director of Nursing (DON) indicated, Resident C admitted to the facility on [DATE] and had necrotic toes at that time. She went down to see the resident and the toes on her left foot looked like they could fall off at any time. She was seen by the doctor the day after she admitted and treatments for the area remained the same. They were going to monitor the area until she was supposed to have a follow up ortho visit on 3/28/22 but the DON indicated she had too much going on, and she forgot the appointment. Then the resident had a decline in her health and since she was a full code status, she was sent to the ED. When discrepancies between the hospital discharge paperwork and facility's admission documentation related to the wounds were questioned, the DON agreed the facility's admission documentation did not reflect the severity of the level of necrosis and gangrene to the left foot/toes. Based on observation, interview and record review, the facility failed to treat a resident with Diabetes Meletus as ordered by the hospital discharge instructions for diabetic medication and diabetic wound care resulting in Resident B having significant risk of hypo/hyperglycemia and wound deterioration or infection and the facility also failed to ensure care was given for diabetic wound care, IV antibiotics (Resident E), and non-pressure wound care (Resident C and D) for 4 of 9 residents reviewed for quality of care. The Immediate Jeopardy began on 3/18/22 at 7:14 p.m. when Resident B was admitted to the facility from the local hospital. The resident's hospital discharge paperwork indicated the resident was receiving Accuchecks and insulin on a sliding scale at the hospital and received treatment for multiple wounds on the legs, feet and toes. The hospital discharge notes indicated the Accuchecks, insulin, and wound treatments should have been continued at the facility. The facility failed to continue to assess and document the resident's wounds after admission. The nurses did not receive orders for wound treatments or document any treatments to the wounds. There were no orders for Accuchecks (rapid blood sugar testing) or diabetic medication since admission, and the facility failed to assess the residents blood sugar since admission. The physician was not notified of the missing diabetic care orders or the wounds. A medication for edema in the lower extremities was ordered but needed clarification for the missing dosage. The facility failed to obtain the clarification and the medication was not administered. The Administrator, Director of Nursing, and the Regional Nurse Consultants were notified of the immediate jeopardy at 3:20 p.m. on 4/5/22. The immediate jeopardy was removed, but noncompliance remained at a lower scope and severity of isolated no actual harm with potential for more than minimal harm that is not immediate jeopardy, on 4/7/22 when the facility audited all the diabetic residents and residents with new admissions for medication, diet, and wound care orders and completed nursing staff education for the new admission process. Findings include: 1. On 4/5/22 at 10:05 a.m., during an observation and interview, Resident B was lying in bed watching television. Both of his legs were wrapped in gauze, from his knees to his ankles. There was no date or time on the bandages. His toes were blackened with dark crusty patches and his right great toe appeared to be partially missing. Both feet appeared swollen. The right foot was swollen, much larger than the left. The right foot was ashen gray, and the left foot was bright red and shiny. The toenails were long and yellow brown in color. The resident indicated the wounds were from his diabetes and he was unable to wear shoes comfortably. He had stopped taking his diabetic pills at home because he thought he didn't need them That was what caused his problems and landed him in the hospital. The facility had wrapped gauze on his legs a couple times. They did not do any kind of daily treatments like he had in the hospital. He had a lot of pain in his legs, they hurt all the time. He rated his pain as 6 out of 10. They gave him some Advil or something like that. It helped a little bit. On 4/5/22 at 3:15 p.m., the medical record was reviewed for Resident B. The diagnoses included but were not limited to diabetes with neuropathy (nerve pain), cellulitis (skin infection) right lower limb (leg), and congestive heart failure. On 3/18/22 at 7:14 p.m., in a progress note Licensed Practical Nurse (LPN) 11 indicated Resident B had arrived to the facility by stretcher. He was alert and oriented and a full code. He was a fall risk, needed assistance of one, and used a walker to ambulate. The resident was continent of bowel and bladder and used a urinal. The medical history included diabetes, hypertension (high blood pressure) and coronary artery (heart disease) with surgery in 2001. Diet was no more than 3,000 milligrams (mg) salt per day and no more than 75 grams (gm) of carbohydrates per meal, regular consistency, and thin liquids. He had 2 plus (+) edema (swelling) to bilateral lower extremities. Resident B had ulcers on both lower legs and vascular disease. His right buttocks had an open area with instructions to cleanse with soap and water, pat dry, apply sensicare ointment, and cover with methiplex border (type of bandage). His right lower extremity had an area with instructions to cleanse with mild soap and water, apply medihoney alginate, abd (padded dressing), and secure with kerlix (gauze wrap) and stretch net. His toes had wounds with instructions to apply betadine to all toes. His left dorsal foot had a blister with instructions to allow betadine to dry, secure with kerlix and stretch net. The dressings should be changed every other (qod) day and as needed (prn). Resident positive for MRSA (infection in wounds). Resident B's last blood sugar was 152. Resident had no complaint of pain or discomfort. A review of Resident B's hospital transfer documents, dated 3/18/22, indicated the following: Future clinic visits were scheduled on 3/25/22 at 12:00 p.m. for a Lab Blood Draw, on 3/25/22 at 12:30 p.m. to check-in for the appointment, and on 3/25/22 1:00 p.m. for the Geriatrics Practitioner appointment. On 3/28/22 at 11:45 a.m. for a Lab Blood Draw, on 3/28/22 at 12:45 p.m. for the appointment check in, and on 3/28/22 at 1:00 p.m. for the Geriatrics Practitioner appointment. An appointment for Vascular surgery was to be scheduled in 1 to 2 weeks. The reasons the patient was admitted to the hospital were skin infection and ulcers on his legs due to vascular disease. He was diagnosed with cellulitis which improved with antibiotics (vancomycin and unasyn). The MRSA (methicillin resistant staph aureous) screening was positive. The hospital transfer documents, dated 3/18/22, indicated Resident B was to continue taking these medications: acetaminophen (Tylenol) 650 milligrams (mg) by mouth every 6 hours aspirin enteric coated 325 mg by mouth once a day atorvastatin (blood pressure medicine) 40 mg by mouth every p.m. cholecalciferol (vitamin D3) 50 mg by mouth every day clopidogrel (blood thinner) 75 mg by mouth daily melatonin (sleep aid) 6 mg by mouth every p.m., as needed multivitamin with minerals, prenatal cap one by mouth daily polyethylene glycol (laxative) 3350 powder one packet by mouth daily sacubitril/Valsartan (reduces blood pressure and improves circulation) one tablet twice a day sennosides (stool softener) tab give 8.6 mg by mouth twice a day spironolactone (blood pressure and fluid retention) 12.5 mg by mouth daily The hospital transfer documents, dated 3/18/22, indicated Resident B was on a modified diet of low salt with no more than 3,000 mg of salt per day, and limited carbohydrates with no more than 75 gram (g) per meal The hospital transfer documents, dated 3/18/22, indicated Resident B's Hgb A1C (indicates high blood sugar over a 3 month period, diabetes) was 7.7 % with a diabetic range of 6.5% or higher and a normal range of below 5.7%. Resident B indicated he was prescribed metformin (diabetic pill) but had not taken it for several weeks. Will restart metformin on discharge. QID [four times a day] glucose checks, sliding scale insulin correction 1:60 and PCP [primary care physician] follow-up. A hospital physician summary notation, dated 3/17/22 at 12:39 p.m., indicated, .States he can't tell much difference in his right leg after stenting yesterday. He had initially declined to consider SNF [skilled nursing facility], but after I spoke with him today about whether he thinks he can take care of his wounds himself. He agreed that he cannot and that it would be better if he had assistance with wound care. He also agreed that he needs to have better nutrition and get stronger prior to returning home. In view of all this he is now agreeable to short-term SNF after discharge, but 'I don't want to die there'. The hospital medication list from the hospital transfer paperwork had ink check marks beside each medication. A handwritten notation beside the Valsartan order indicated, Need clarification on strength. The admission Assessment form completed by LPN 11, on 3/18/22 at 6:30 p.m., included but was not limited to: Diet was no more than 75 gm of carbs per meal, regular consistency, and thin liquids. Skin had LLE (left lower extremity) vascular ulcers, right buttock OA [open area], RLE [right lower extremity] vascular ulcers. Resident had ulcers of vascular disease to the bilateral lower extremity (BLE), the right buttocks, has an OA, RLE had a wound, treatment was in place. The resident had a telehealth progress note for Admission, on 3/23/22 at 1:28 p.m., entered by the facility physician. The note indicated the resident was seen for chief complaint of cellulitis right lower limb, congestive heart failure, diabetes II with neuropathy and alcoholic liver disease. Resident B was seen and examined for new admission. The current medications were listed. There was no descriptions of the resident's wounds and no treatment orders listed. No orders for diabetic medication, labs or blood sugars were ordered. There were no new orders. Weekly skin check documentation, dated 3/25/22 and 4/1/22, indicated the resident had existing areas of loss of skin integrity and no new loss of skin integrity. The form indicated the existing areas were to be updated on the Weekly Wound Evaluation for each existing area of loss. There were no Weekly Wound Evaluations in the medical record. There was no wound description or measurements. There was no record of treatments. A review of the resident's current physician orders did not include any dressing change orders or treatment orders for the resident's wounds on the bilateral legs or buttocks. There was no order for Valsartan. The resident did not have orders for blood glucose testing, Accuchecks or any diabetic medication. There were no orders for the resident to return to the hospital clinic on 3/25/22 and 3/28/22, or to schedule an appointment in 1-2 weeks with the vascular surgery clinic. There was no documentation in the record that indicated the resident had returned to the hospital clinic since his admission to the facility. A review of the medication administration record (MAR) and treatment administration record (TAR) since admission did not include any blood sugar testing/Accuchecks, diabetic medication, or wound care. The resident's diet order was General diet, regular texture, thin liquid consistency. There was no code status order. The resident had not received any Valsartan and it was not listed as a medication order. The resident's code status was blank on the Face Sheet and electronic record information bar. A review of Resident B's Baseline Care Plan Code Status section was blank, advanced directive indicated n/a (not applicable). Section 3A Special Treatment/ Health conditions indicated receives a treatment to his legs. Section 3H Safety Risks indicated receives a treatment to legs daily. Section 4A Dietary indicated Diet order: General. The resident did not have a comprehensive care plan for wound care/skin integrity or diabetes. On 4/4/22 the Minimum Data Set (MDS) Coordinator entered a new Care Plan for Resident B on 4/4/22. The focus was Diabetes with risk for hypo/hyperglycemia and the goal was Will have no s/sx of hypo/hyperglycemia daily. The interventions were to provide antidiabetic medicines per order; check blood sugars per order; perform labs per order; monitor for signs and symptoms (s/sx) of hyperglycemia such as, but not limited to be flushed, fruity breath, thirst, and/or diaphoretic; monitor for s/sx of hypoglycemia such as pale, clammy, cool, thready pulse, lethargy; Notify MD and family as needed; and observe and report any signs of skin breakdown for example the feet and lower extremities. During an interview, on 4/4/22 at 4:00 p.m., the Director of Nursing (DON) indicated Resident B was admitted on [DATE]. Only the Director of Nursing (herself) or the Assistant Director of Nursing (ADON) did all the resident admissions. She had done Resident B's admission herself. He did not need blood sugars or diabetic medication according to his hospital discharge. There was a list of medications to continue. Those were the ones entered for his orders. The Valsartan was not ordered because there was no strength given. She was unsure if anyone followed up on the missing strength. He did not receive any blood sugars or diabetic medication. They had not ordered any treatments for his legs. He had gauze on them because he liked for them to be wrapped and would ask the nurses to do it. There was no order for it. The dressing was not documented. He did not have orders to see wound care or be treated by them. They had never seen him. He had not had any labs done that she knew of. He did not get blood sugar checks/Accuchecks, and none had been done. He was diabetic but wasn't getting any treatment for it (insulin or oral medication). He did receive insulin and Accuchecks in the hospital, but it had not been ordered at the facility. On 4/4/22 at 4:20 p.m., during an observation and interview, Resident B was lying on his bed, an unidentified staff member was removing the gauze dressing from his left leg. The right leg bandage was still intact. The resident's calf had 4 quarter sized blackened areas with inflammation (bright red tissue) around the perimeter of the blackened tissue. He was able to wiggle his toes and lift his legs to command to help with visualization. There was swelling noted to the left calf and foot. The foot was bright red and shiny. He indicated his pain was a 6/10 all the time. During the observation he was eating a one pound canned ham, directly from the can. During an interview, on 4/5/22 at 8:40 a.m., the DON indicated her and the ADON did do all the facility admissions but recently they had been having new hire nurses do the admissions and that was what happened with Resident B's admission. It was completed by one of the other nurses. They were training them to do admissions during orientation. She did not know if Resident B had been out to any clinic appointments since admission. During an interview, on 4/5/22 at 8:58 a.m., Qualified Medication Aid (QMA) 8 indicated she normally worked a different hall. She had worked the other hall yesterday and it was her first time working with Resident B. He was pretty quick and easy as far as medication pass. She had remembered him talking about going home. She did not know if he was confused. They found physician orders and what treatments to give during medication pass from the MAR, she could only remember 4 residents with Accuchecks yesterday. Resident B was not one of them. It would surprise me to know that he was a diabetic, because he did not have any orders for Accuchecks or insulin. She indicated she was unaware he had cellulitis. It was important to have full accurate order sets in the MAR since she was an agency nurse and she worked with different residents a lot of the time. During an interview, on 4/5/22 at 9:09 a.m., Licensed Practical Nurse (LPN) 9 and QMA 10 indicated they were the care givers for another hall. They both indicated they had never cared for Resident B before. Together they checked his orders and indicated he had never had an Accuchecks done in the facility since admission. He did not receive Accuchecks or receive any diabetic medication. During an interview, on 4/5/22 at 10:54 a.m., the DON indicated she contacted the physician on 4/4/22 and the Nurse Practitioner (NP) would see Resident B on 4/5/22. The physician and NP only did telehealth (video) visits, they wouldn't come into the facility. The physician had done a telehealth visit with the resident after admission. He had access to the hospital discharge papers and did not order anything additionally. Standards of practice did not trigger them to contact the physician for additional orders for wound care or diabetic medications or blood sugars. His cellulitis was healed. They only put dressings on because he wanted them to. He had stopped his own diabetic medication at home before he went to the hospital. During an interview, on 4/5/22 at 11:45 a.m., the DON indicated she had no answer to whether the resident had gone to appointments at the clinic or not. She was trying to get in touch with transportation to see if they took him anywhere. He did refuse some things. There is no documentation of the resident going out for any appointments or returning with any physician notes. If it happened there should be notes. On 4/5/22 at 12:53 p.m., the DON provided a written statement she indicated was from the facility transporter. The transporter had not taken Resident B to any appointments. She indicated the hospital picked up the residents themselves. They had not come to take him. The appointments were canceled. He had another appointment for 4/22/22, to go to the vascular clinic. She indicated the admission note, in the resident record, entered by LPN 11 was based on the report she had gotten from the hospital when Resident B was being transferred to the facility. The DON had not done that admission, she was mistaken. LPN 11 had done it. She did not know why the admission note wasn't consistent with the resident's physician orders. On 4/5/22 at 2:46 p.m., the Administrator provided a current, undated policy, titled admission Guidelines. This policy indicated .All applicants for admission will be individually assessed for reasonable accommodation, ensuring that no barriers to admission of whole diagnostic groups or conditions occurs. The pre-admission evaluation of each prospective resident must ensure that only those individuals are admitted whose medical/psychosocial needs can be met by the facility. The facility must have an order for immediate care written by a currently licensed physician for admission of an individual to the facility. An evaluation of each resident shall be made, prior to admission, which shall include personal or telephone interviews with the resident, the resident's physician, or the representative of the facility from which the resident is being transferred, if applicable. At the time each individual is admitted , the facility must have physician's orders for immediate care that are based on a physical examination performed by a currently licensed attending physician or his /her designee, written on the day of admission or within 30 days prior to admission On 4/5/22 at 2:46 p.m., the Administrator provided a current, undated policy, titled Physician's Orders- (Following Physician Orders). This policy indicated It is the policy of the facility to follow the orders of the physician. At the time of admission, the facility must have physician orders for the resident's immediate care. The facility will have orders to provide essential care to the resident, consistent with the resident's mental and physical status upon admission. The facility must have orders upon admission from the physician for: dietary, drugs (if necessary), routine care to maintain or improve the resident's functional abilities until staff can conduct a comprehensive assessment and develop an interdisciplinary care plan. AS assessments are completed, orders will be received from the physician to address significant findings of the assessments. Orders that accompany the resident on admission will be clarified by the physician through action of the nurse who will contact the physician for clarification upon the resident's admission According an article from the American Diabetes Association, titled, Glycemic Targets: Standards of Medical Care in Diabetes-2022, dated 12/16/21and retrieved on 4/5/22 at https://doi.org/10.2337/dc22-S006, indicated, The American Diabetes Association (ADA) 'Standards of Medical Care in Diabetes' includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care .Glycemic control is assessed by the A1C measurement, continuous glucose monitoring (CGM) using either time in range (TIR) and/or glucose management indicator (GMI), and blood glucose monitoring (BGM). A1C is the metric used to date in clinical trials demonstrating the benefits of improved glycemic control. Individual glucose monitoring is a useful tool for diabetes self-management, which includes meals, exercise, and medication adjustment, particularly in individuals taking insulin. CGM serves an increasingly important role in the management of the effectiveness and safety of treatment in many patients with type 1 diabetes and in selected patients with type 2 diabetes. Individuals on a variety of insulin regimens can benefit from CGM with improved glucose control, decreased hypoglycemia, and enhanced self-efficacy The immediate jeopardy that began on 3/18/22 was removed on 4/7/22 when the facility audited all the diabetic residents and residents with new admissions for medication, diet, and wound care orders and completed nursing staff education for the new admission process. The noncompliance remained at the lower scope and severity level of isolated no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring. 2. On 4/4/22 at 10:31 a.m., during an observation and interview, Resident E was watching television seated in a recliner in her room. An intravenous (IV) pole was on her right. A completed bag of IV antibiotic medication hung on the pole. There was no date or time on the tubing or hang time on the bag. A PICC (peripherally inserted central catheter) was visible in the resident's upper right arm. The dressing was dated 3/22/22. Her left foot was wrapped in an ACE bandage (compression bandage). A tubing connected the bandage to a wound vacuum (vac) machine to the resident's left. There was no date or initials visible on the dressing. The Resident indicated she had come to the facility for rehab and IV antibiotics. She had surgery on her foot because of an infection and sore from her diabetes. She was supposed to go home soon, maybe a week or so, because her two or three weeks of antibiotics would be finished. Her PICC line dressing had not been changed since she came to the facility. That dressing she had on was done at the hospital. The wound vacuum (vac) dressing was supposed to be changed on Monday, Wednesday, and Friday. It had not been done yet th[TRUNCATED]