**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review and facility policy review the facility failed to promote the healing of existing pressure injuries as evidenced by failure to perform hand hygiene during wound care. Resident #34 currently has a foul odor and purulent discharge to facility acquired pressure wounds of the right lower leg and right heel with a history of recent multiple pressure ulcer infections. Resident #42 has two (2) facility acquired pressure ulcers with a history of pressure ulcer infection. This is for two (2) of five (5) residents reviewed for pressure ulcers. (Resident #34 and Resident #42). Findings include: Review of the facility policy titled, Wound Care, revised October 2010, revealed, Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Steps in procedure: 2.) Wash and dry hands thoroughly.4.) Put on exam gloves, loosen tape, and remove dressing.5.) Pull gloves over dressing and discard. Wash and dry hands thoroughly .6.) Put on gloves.23.) Wash and dry hands thoroughly. Review of the facility policy titled, Handwashing/Hand Hygiene, revised August 2019, revealed, Policy Statement: The facility considers hand hygiene the primary means to prevent the spread of infections.Policy Interpretation and Implementation: 7.) Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following.) Before handling clean or soiled dressings, gauze pads, etc.h.) Before moving from a contaminated body site to a clean body site during resident care.i.) After contact with a resident's skin. j.) after contact with blood or bodily fluids.k.) After handling used dressings, contaminated objects. m.) After removing gloves. An observation and interview during the initial tour on 2/26/24 at 4:00 PM revealed a foul odor was coming from the room of Resident #34. An interview with the Registered Nurse (RN)-Wound Care Nurse that was in the resident's room revealed Resident #34 has pressure ulcers, some of them are having some malodorous drainage and she obtained an order to culture the wounds. Review of the physician's orders for Resident #34, revealed Right Lateral lower leg pressure ulcer stage 3: clean with NS (normal saline), apply Santyl to wound bed, cover with boarder dressing daily and prn (as needed).Right heel unstageable: cleanse with spray wound cleanser pat dry, apply Santyl ointment to wound bed then calcium alginate to slough, wrap with kerlix, and secure with paper tape daily and prn Unstageable wound to Dorsalis Pedis Right, cleanse with wound cleanser, pat dry with 4 x 4, apply Santyl ointment to wound bed, cover with ABD (abdominal gauze pad) then wrap with kerlix qd (every day) and prn. During an interview and record review of the treatment record for Resident #34 on 2/27/24 at 9:55 AM with the Registered Nurse (RN)- Wound Care Nurse, revealed that the wound to the right dorsalis pedis should read DTI (Deep Tissue Injury) not unstageable and she would do a clarification order. She stated that the right heel is now presenting as a stage 4 and would clarify that as well. An observation and interview during wound care for Resident #34 with the RN-Wound Care Nurse and Licensed Practical Nurse (LPN) #1 on 2/27/24 at 10:00 AM, revealed the RN-Wound Care Nurse sanitized hands applied gloves and verbalized during wound care she always cleans the peg (percutaneous endoscopic gastrostomy) site, the Foley catheter site first and then takes care of the wounds. She then cleaned around the stoma of the peg tube site and applied a clean dressing around the site with the same gloves used to clean the peg stoma site . The RN-Wound Care Nurse then pulled down Resident #34s brief and cleaned around the Foley catheter with a wet washcloth with the same gloves used to perform peg site care with no hand hygiene before or after the catheter care. The RN-Wound Care Nurse then removed the glove off her right hand and applied a clean glove, left the dirty glove on her left hand, began to cut, and date tape with no hand hygiene performed. LPN #1 performed hand hygiene, removed dressings off the resident's right heel, right dorsalis pedis area (top of right foot), and right lateral leg then discarded them in a red bag. She then grabbed moistened gauze and patted the leg wound once and discarded the gauze, then patted the right heel wound bed once and discarded the gauze, and patted the right dorsalis pedis wound bed with a gauze pad and discarded it with no hand hygiene performed between wounds. LPN #1 then applied an ointment to the wound bed of each wound with the same gloves used to remove the soiled dressings and clean the wound beds, the RN- Wound Care nurse then handed LPN #1 clean dressings and dated tape to cover the wounds with the same contaminated gloves worn during catheter care. LPN #1 applied clean dressings and dated tape, removed her gloves, and performed hand hygiene. Record review of the Wound Assessment Details from the local hospital for the right lateral leg lower pressure ulcer assessments revealed initial onset 11/27/23. Further review of the Wound Assessment Report revealed last assessment dated [DATE] now a stage 3 measuring 5.50 cm (centimeters) length x (times) 1.30 cm width x 0.50 cm depth. This wound was facility acquired. Record review of the Wound Assessment Report for the right heel pressure ulcer assessments revealed initial 9/21/23 DTI (deep tissue injury) measuring 1.60 cm length x 1.00 cm width. Further review revealed last assessment dated [DATE] now worsened to a stage 4, measuring 7.00 cm length x 6.00 cm width x 0.20 cm depth. This wound was facility acquired. Record review of an Infection Report-Basic for Resident #34 dated 12/3/23, revealed a culture of the right heel pressure ulcer with growth of Proteus mirabilis- Intervention: Ceftriaxone 1 (one) gram IV (intravenous) daily times 10 days ordered related to right heel wound infection. Infection source: It is likely infection developed in the facility. Review of an Infection Report-Basic for Resident #34 dated 12/22/23 culture of right heel pressure ulcer related to purulent/malodorous drainage with growth of multiple organisms Bacteroides fragilis, Staphylococcus aureus, Enterococcus faecalis, Finegoldia [NAME], [NAME] morganii, and Proteus mirabilis. Treated with Invanz 1-gram IV daily times 10 days and Tygacil 50 mg (milligrams) IV every 12 hours times 10 days. Record review of the Wound Assessment Report for the right dorsalis pedis revealed initial onset of 2/14/24 as a DTI measuring 4.50 cm length x 4.50 cm width x 0.25 cm depth. Further review of the Wound Assessment Report dated 2/21/24 revealed the DTI measuring 5.00 cm length x 5.00 cm width x 0.25 cm depth. This revealed an increase in size of the wound and this wound was facility acquired. A review of a physician's order for Resident #34 dated 2/25/24 revealed an order to obtain wound culture on 2/26/24 related to foul odor and purulent discharge to wounds right lower leg and right heel. An interview with the RN-Wound Care Nurse on 2/27/24 at 2:30 PM, confirmed she had noticed an increase in the number of wound infections that Resident #34 has had and confirmed there was worsening to all her wounds. She then confirmed she did not perform hand hygiene between any of the treatments for Resident #34 and stated it did not occur to her to wash her hands after cleaning the peg tube, catheter care, and wound care revealing she normally sanitizes her hands before she starts the treatments of a resident and when she finishes doing all the treatments for the resident. She revealed that not performing hand hygiene between the treatments could lead to cross contamination and could have resulted in increased risk for infections and may cause wounds to worsen or cause a systemic infection. An interview with the Infection Control (IC) nurse on 2/27/24 at 3:00 PM, revealed she has watched the RN-Wound Care Nurse do treatments in the past and she did break infection control barriers and was educated. She revealed she had noticed the increase in the number of wound infections and had done three one on one check offs with the RN-Wound Care Nurse related to wound care but did not document the check offs. She revealed she had reported to the Administrator and the Director of Nurses (DON) on Friday 2/23/24 of her concerns with the RN-Wound Care Nurse but was unaware of the finding of what they did. She verbalized that these residents are vulnerable and more susceptible to infection and confirmed failing to perform hand hygiene during treatments and between different treatments increased the risk for infections and could have been a factor in the increase in wound infections. An interview with the Administrator and the DON on 2/27/24 at 4:00 PM, revealed that they were aware that the RN-Wound Care Nurse was having problems with time management but was unaware of her having any infection control issues. The Administrator also revealed they have met with the RN-Wound Care Nurse on several occasions about her understanding of her role and time management and had reached out to HR (Human Resource) on Monday 2/26/24 about beginning a 30-day performance program of action to see improvement. The DON confirmed that failing to perform hand hygiene between treatments and during wound care places the residents at risk for increased infection and worsening wounds. An interview with LPN #1 on 2/28/24 at 8:49 AM, confirmed she did not perform hand hygiene while doing wound care to Resident #34's wounds. She revealed that she was unaware that she should have performed one treatment at a time and performed hand hygiene in between cleaning the wounds and applying the clean wound supplies but confirmed that she can see where that would be cross contamination and lead to increased risk for infection. A phone interview with the Medical Director on 2/28/24 at 9:34 AM, confirmed that poor infection control practices could lead to wound infections and worsening of wounds. Record review of Resident #34's Face Sheet revealed that the resident was admitted to the facility on [DATE] with medical diagnoses that included Atherosclerotic heart disease of native coronary artery. Record review of Resident #34's Minimum Data Set (MDS) Section M with an Assessment Reference Date (ARD) of 12/04/23 revealed M0210 was coded as yes resident has one or more unhealed pressure ulcers/injuries. Resident #42 Record review of Resident #42's Wound Assessment Report revealed the resident currently has three pressure wounds revealing the following: -Wound to the Sacrum -Stage 3-Identified on 11/18/19 after readmission from the hospital with measurements of 9.00 centimeters (cm) (length) x 11.00 cm (width) x 0.20 cm (depth) and a current measurement on 2/22/24 of 7.50 cm x 7.90 cm x 0.40 cm with a wound status of Improved. -Wound to the Right Buttock; lower-Stage 2-Identified on 2/9/23-facility acquired-with measurements of 1.50 cm x 2.00 cm x 0.10 cm and a current measurement on 2/22/24 of 1.90 cm x 1.30 cm x 0.30 cm Stage 3 with a wound status of Improved. -Wound to the Right Lateral Shin; right medial leg lower-Stage 3-Identified on 1/30/24-facility acquired-with measurements of 2.20 cm x 1.20 cm x 0.20 m and a current measurement on 2/22/24 of 1.70 cm x 0.60 cm x 0.01 cm with a wound status of Improved. An observation on 2/27/24 at 1:26 PM revealed RN-Wound Care Nurse, LPN #2 and Certified Nurse Assistant (CNA) #1 with Resident #42 for wound care. RN-Wound Care Nurse washed her hands, applied gloves, and cleaned the supra pubic catheter. She removed those gloves, did not perform hand hygiene, applied new gloves, pulled the residents draw sheet that revealed bowel movement on the bed pad draw sheet and up the residents back above the brief and on the legs below the brief. She removed the residents brief which revealed the resident's buttocks were covered in bowel movement, removed the coccyx wound dressing and the lower buttock wound dressing which revealed there was bowel movement under the dressings and in the wounds. She cleaned the bowel movement up with a washcloth and warm water, no soap, removed gloves, did not perform hand hygiene, applied new gloves, and cleaned the coccyx wound with normal saline. She then removed her gloves, did not perform hand hygiene, applied new gloves, applied silver cell to the coccyx wound, covered it with a 4x4 pad, and covered that with an ABD pad. She then rolled the dirty brief under the wound and held the pad in place while LPN #2 took her gloves off, washed her hands and handed RN-Wound Care Nurse the tape for the dressing. She then taped down the dressing, removed the dirty brief and put it in a biohazard bag, applied two more pieces of tape to the coccyx wound dressing, removed gloves, picked up new gloves then laid them back inside the box with multiple clean gloves. She washed her hands then applied those same gloves that she had picked up and laid down. She cleaned the lower left buttock wound removed gloves, did not perform hand hygiene, put on new gloves, and helped apply a new brief. An interview on 2/27/24 at 2:50 PM with LPN #2 confirmed that RN-Wound Care Nurse did not wash her hands when she changed her gloves and should have. She confirmed that was a break in infection control and could lead to the spread of infections. An interview with RN-Wound Care Nurse on 2/27/24 at 3:40 PM confirmed that she broke infection control when she was doing wound care on Resident #42 by not washing her hands after changing gloves from a dirty procedure, which could cause a spread of infection or cross contamination leading to a wound infection. Record review of Resident #42's Final Report for the residents wound culture from the Coccyx wound with a final result date of 11/17/23. This culture revealed a result of Acinetobacter baumannli, Bacteroides fragilis, Escherichia coli, Morganella morganii, Proteus mirabilli, Pseudomonas aeruginosa, Clostridium perfringens, Enterococcus faecalis with an order to start Levaquin 500 milligram (mg) 1 tab via PEG tube daily for 14 days (Start 11/27-Stop 12/10) Record review of Resident #42's Infection Report-Basic dated 11/27/23 revealed the resident had a wound infection that indicated Infection Source: It is likely infection developed in the facility. Record review of Resident #42's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Sequelae of Cerebral Infarction. Record review of Resident #42's MDS with an ARD of 1/22/24 revealed in Section C a Brief Interview for Mental Status (BIMS) with no score, which indicates the resident is severely cognitively impaired and in Section M that the resident had one or more unhealed pressure ulcers at Stage 1 or higher.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review and facility policy review the facility failed to perform hand hygiene during wound care, Foley and suprapubic catheter care, and Percutaneous Endoscopic Gastrostomy (PEG) tube care (Resident's #34 and #42) Resident #34 currently has a foul odor and purulent discharge from facility acquired pressure wounds of the right lower leg and right heel with a history of recent multiple pressure ulcer infections. Resident #42 has two (2) facility acquired pressure ulcers with a history of pressure ulcer infection. This is for two (2) of 10 residents observed during direct patient care. Resident's #34 and 42 Cross reference F686 Findings include: Review of the facility policy titled, Standard Precautions, effective 01/01/2020, revealed, Policy: Standard Precautions are designed for care of all patients in facilities, regardless of diagnosis or presumed infection status, to reduce the risk of transmission from both recognized and unrecognized sources of infection.Standard Precautions include Gloves: To be worn when touching blood, body fluids, secretions, mucous membranes, non-intact skin, and other contaminated items .Gloves do not take the place of hand hygiene .Hands are to be washed after removing gloves .Gloves should be changed between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. Review of the facility policy titled, Handwashing/Hand Hygiene, revised August 2019, revealed, Policy Statement: The facility considers hand hygiene the primary means to prevent the spread of infections .Policy Interpretation and Implementation: 7.) Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following. Before handling clean or soiled dressings, gauze pads, etc.h.) Before moving from a contaminated body site to a clean body site during resident care.i.) After contact with a resident's skin. j.) after contact with blood or bodily fluids.k.) After handling used dressings, contaminated objects. m.) After removing gloves . Review of the facility policy titled, Catheter Care, revised September 2014, revealed, Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections .Infection Control: 1.) Use standard precautions when handling or manipulating the drainage system . Review of the facility policy titled, Gastrostomy/Jejunostomy Site Care, revised October 2011, revealed, Purpose: The purpose of this procedure is to promote cleanliness and to protect the gastrostomy or jejunostomy site from irritation, breakdown and infection Steps in the procedure: 2.) Wash hands and dry thoroughly.2.) Wear clean gloves.14. Remove gloves and discard. 15.) Wash your hands . Review of the facility policy titled, Wound Care, revised October 2010, revealed, Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Steps in procedure: 2.) Wash and dry hands thoroughly .4.) Put on exam gloves, loosen tape, and remove dressing .5.) Pull gloves over dressing and discard. Wash and dry hands thoroughly .6.) Put on gloves.23.) Wash and dry hands thoroughly . Observation of wound care for Resident #34's wound care with the (Registered Nurse) RN-Wound Care Nurse and Licensed Practical Nurse (LPN) #1 on 2/27/24 at 10:00 AM revealed, the RN-Wound Care Nurse sanitized hands applied gloves and verbalized during wound care she always cleans the PEG tube site, and the Foley catheter site first and then takes care of the wounds. She then cleaned around the stoma of the PEG tube site and applied a clean dressing around the stoma site with the same gloves used to clean the PEG stoma site. The RN-Wound Care Nurse then pulled down Resident #34's brief and performed catheter with the same contaminated gloves used to perform PEG site care. There was no observation of hand hygiene before or after the Foley catheter care. The RN-Wound Care Nurse then removed the glove off of her right hand and applied a clean glove, began to cut, and date tape, with no observation of hand hygiene and no observation of removing the soiled glove from the left hand. LPN #1 performed hand hygiene, removed dressings off of the residents right heel, right dorsalis pedis area (top of right foot), and right lateral leg and discarded them in a red bag. She then grabbed moistened gauze and patted the leg wound once and discarded the gauze, then patted the right heel wound bed once and discarded the gauze ,and patted the right dorsalis pedis wound bed with a gauze pad and discarded it with no observation of hand hygiene between cleaning each wound. LPN #1 then applied an ointment to the wound bed of each wound with the same gloves used to remove the soiled dressings and clean the wound beds. The RN-Wound Care Nurse then handed LPN #1 clean dressings and dated tape to cover the wounds with the same contaminated gloves worn during PEG site and catheter care. LPN #1 applied clean dressings and dated tape, removed her gloves she applied at the beginning of wound care, and performed hand hygiene. Record review of an Infection Report - Basic for Resident #34 dated 12/3/23, revealed an order for a culture of right heel pressure ulcer for foul and purulent drainage with growth of Proteus mirabilis- Ceftriaxone 1(one) gram IV (intravenous) daily times 10 days ordered related to right heel wound infection. Record review of an Infection Report - Basic for Resident #34 dated 12/22/23 culture of right heel pressure ulcer related to purulent/malodorous drainage with growth of Bacteroides fragilis, Staphylococcus aureus, Enterococcus faecalis, Finegoldia [NAME], [NAME] morganii, and Proteus mirabilis. Treated with Invanz 1-gram IV daily times 10 days and Tygacil 50 mg (milligrams) IV every 12 hours times 10 days. A record review of a physician's order for Resident #34 dated 2/25/24 revealed an order to obtain wound culture on 2/26/24 related to foul odor and purulent discharge to wounds. Record review of the facility infection log for dates 9/27/23-2/27/24, revealed there were 11 wound infections. During an interview with the RN-Wound Care Nurse on 2/27/24 at 2:30 PM confirmed she had noticed an increase in the number of wound infections that Resident #34 has had and confirmed there was worsening to all her wounds. She then confirmed she did not perform hand hygiene between any of the treatments for Resident #34 and stated it did not occur to her to wash her hands after cleaning the PEG tube, catheter care, and wound care revealing she normally sanitizes her hands before she starts the treatments of a resident and when she finishes doing all the treatments for the resident. She then confirmed that not performing hand hygiene between the treatments could lead to cross contamination and could have resulted in increased risk for infections and may cause wounds to worsen or cause a systemic infection. During an interview with the Infection Control (IC) nurse on 2/27/24 at 3:00 PM, revealed she has watched the RN treatment nurse do treatments in the past and she did break infection control barriers and was educated. She revealed she had noticed the increase in the number of wound infections and had done three one on one check offs with the treatment nurse related to wound care but did not have documentation and revealed she had reported to the Administrator and DON on Friday of her concerns with the treatment nurse but was unaware of the finding of what they did. She verbalized that these residents are vulnerable and more susceptible to infection and confirmed failing to perform hand hygiene during treatments and between different treatments increased the risk for infections and could have been a factor in the increase in wound infections. On 2/27/24 at 4:00 PM an interview with the Administrator and Director of Nurse (DON) revealed that they were aware that the treatment nurse was having problems with time management but was unaware of her having any infection control issues. The Administrator also revealed they have met with the RN treatment nurse on several occasions about her understanding of her role and time management and had reached out to HR (Human Resource) on Monday 2/26/24 about beginning a 30-day performance program of action to see improvement. The DON confirmed that failing to perform hand hygiene between treatments and during wound care places the residents at risk for increased infection. During an interview with LPN #1 on 2/28/24 at 8:49 AM, revealed that she was unaware that she should have performed one treatment at a time and performed hand hygiene in between cleaning the wounds and applying the clean wound supplies but confirmed she can see where that would be cross contamination and lead to increased risk for infection. She confirmed she did not perform hand hygiene while doing wound care to Resident #34's wounds. During a phone interview with the Medical Director on 2/28/24 at 9:34 AM confirmed that poor infection control practices could lead to wound infections. Record review of the Face Sheet revealed that the facility admitted Resident #34 to the facility on [DATE] with a diagnosis of Atherosclerotic heart disease of native coronary artery. Resident #42 During an observation on 2/27/24 at 1:26 PM revealed Registered Nurse (RN)-Wound Care Nurse, LPN) #2 and Certified Nurse Assistant (CNA) #1 with Resident #42 for wound care. The RN-Wound Care Nurse removed the Percutaneous Endoscopic Gastrostomy (PEG) tube dressing that revealed a yellow drainage around the site. She then cleaned the area, removed her gloves, and did not perform hand hygiene. She applied a new PEG dressing and did not perform hand hygiene before or after applying the new dressing. She then applied new gloves and cleaned the supra pubic catheter. RN-Wound Care Nurse then pulled the residents draw sheet back that revealed bowel movement (BM) on the bed pad, draw sheet, and up the residents back and legs. She removed the residents brief which revealed the resident's buttocks were covered in BM. The RN -Wound Care Nurse removed the coccyx wound dressing and the lower buttock wound dressing which revealed there was BM under the dressings and in the wounds. She cleaned the BM with a washcloth and warm water. She did not use any soap to clean the BM. She removed her gloves but did not perform hand hygiene. After applying new gloves, she cleaned the coccyx wound and changed her gloves did not perform hand hygiene and proceeded to apply the dressing to the coccyx wound. She then rolled the BM soiled brief under the wound and held the pad in place while LPN #2 handed RN-Wound Care Nurse the tape for the dressing. She then taped down the dressing, removed the soiled brief and put it in a biohazard bag, and applied two more pieces of tape to the coccyx wound dressing all while wearing the same gloves. She removed her gloves and did not perform hand hygiene. She then picked up new gloves then laid them back inside the box with multiple clean gloves. She washed her hands then applied those same gloves that she had previously picked up and laid down prior to washing her hands. She cleaned the lower left buttock wound and removed her gloves but did not perform hand hygiene and helped apply a new brief. She then applied new gloves and cleaned the right shin pressure wound. She removed her gloves, washed her hands, picked up a 4x4 off the top of the protected barrier table with wound treatment supplies and dried her hands with it. During an interview on 2/27/24 at 2:50 PM with LPN #2 confirmed that RN-Wound Care Nurse did not wash her hands when she changed her gloves and should have. She confirmed that was a break in infection control and could have led to the spread of infections. During an interview with RN-Wound Care Nurse on 2/27/24 at 3:40 PM confirmed that she did not follow infection control when she was providing wound care for Resident #42 because she did not wash her hands after changing gloves from a dirty procedure, which could cause a spread of infection or cross contamination leading to a wound infection. Record review of Resident #42's Final Report for the residents wound culture from the Coccyx wound with a final result date of 11/17/23. This culture revealed a result of Acinetobacter baumannli, Bacteroides fragilis, Escherichia coli, Morganella morganii, Proteus mirabilli, Pseudomonas aeruginosa, Clostridium perfringens, Enterococcus faecalis with an order to start Levaquin 500 mg 1 tab via PEG tube daily for 14 days (Start 11/27-Stop 12/10) Record review of Resident #42's Infection Report-Basic dated 11/27/23 revealed the resident had a wound infection that indicated Infection Source: It is likely infection developed in the facility. Record review of Resident #42's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Sequelae of Cerebral Infarction. Record review of Resident #42's Minimum Data Set with an Assessment Reference Date of 1/22/24 revealed in Section C a Brief Interview for Mental Status with no score, which indicates the resident is severely cognitively impaired and in Section M that the resident had one or more unhealed pressure ulcers at Stage 1 or higher.