Every finding on record at Grey Wind LLC

Based on a recertification survey conducted from 2/22/22 through 2/24/22, it was determined that Wasatch Home Health was in compliance with the Conditions of Participation for Emergency Preparedness; 42 CFR (Code of Federal Regulations) 484.22 and 484.102. No deficiencies were cited.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on interview and record review, it was determined the Home Health Agency did not ensure that each patient had a comprehensive assessment completed no later than five calendar days after the start of care. Specifically, for 1 of 7 sample patients, the agency did not ensure a comprehensive assessment was completed by the occupational therapist as ordered. (Patient identifier: 6.) Findings include: Patient 6 was admitted to the agency on 12/4/2021 with a diagnosis which included a displaced transverse fracture shaft of the left femur. Patient 6's medical record was reviewed on 1/23/2022. At the time of discharge, an order was given for an occupational therapist (OT) to evaluate patient 6 and treat as indicated. There was no documentation in patient 6's medical record that indicated an OT evaluation had been completed as ordered. On 2/23/2022 at 3:01 PM, a telephone interview was conducted with the administrator and the director of nursing (DON) for the St. George area related to the missing OT evaluation. The DON stated that the physical therapist (PT) normally completed the OT evaluations as long as it was within his scope of practice. The DON stated that he was not sure what had happened and why the OT evaluation had not been completed as ordered. The administrator and the DON confirmed the OT evaluation had not been completed as ordered.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, it was determined the agency did not ensure all patient care orders, including verbal orders, were recorded in the plan of care (POC) for 3 of 7 sample patients and 1 supplemental patient. (Patient identifiers: 1, 6 and 8.) Findings include: 1. Patient 8 was admitted to the agency on 11/3/2021 with a non-pressure chronic ulcer of the right calf. Patient 8's POC for the certification period of 1/2/2022 to 3/2/2022 revealed a wound care order for the non-pressure ulcer wound to patient 8's lower left leg. The order indicated that using aseptic technique, the skilled nurse (SN) was to clean/irrigate the wound with normal saline (NS), dry with gauze, prepare skin to peri-wound with skin prep, fill wound cavity with black foam, cover and secure with drape and apply tubing. Then apply the negative pressure device at 125 MMHG (millimetre of mercury) continuously. On 1/3/2022, 1/17/2022, and 1/31/2022, new wound care orders for the non-pressure ulcer to patient 8's lower left leg were sent to the agency. None of these order changes were reflected in patient 8's current plan of care. In an email, on 2/24/2022 at 10:00 AM, the director of nursing (DON) for the Salt Lake (SL) area stated, "I was under the assumption that each new wound clinic order superseded any previous order therefore updating the POC…" On 2/24/2022 at 10:06 AM, a telephone interview was conducted with DON for the SL area. The DON confirmed she was unaware that the plan of care itself needed to be updated to reflect current orders, treatments, or medications. She further stated the agency was using the physician order as the update. 2. Patient 1 was admitted to the agency on 1/15/2022 with diagnoses which included an autistic disorder and a cutaneous abscess of the abdominal wall. Patient 1's medical record was reviewed on 1/23/2022. The admitting nurse documented on the Outcome and Assessment Information Set (OASIS) assessment that homecare was needed for wound treatment due to an abdominal abscess with cellulitis. The nurse did not document the size or description of the wound. The nurse documented that the wound was cleaned with normal saline, applied a silver antibacterial ointment, covered with the wound with telfa and secured the dressing with tegaderm. The POC for the certification period of 1/15/2022 to 3/15/2022 was reviewed. The POC did not include wound care orders. On 1/17/2022, a physician's order was received to treat the abdominal abscess as follows, "Clean inside and surrounding wound with NS then betadine swabs. Apply colloidal silver. Cover with non-adherent dressing. Secure with tegaderm." The POC was not updated to include the new order. On 2/23/2022 at 4:13 PM, a telephone interview was conducted with the DON of the SL area related to the missing treatment orders on the POC. The DON stated she did not know why the treatment orders did not "pull over" onto the POC. 3. Patient 6 was admitted to the agency on 12/4/2021 with a diagnosis which included a displaced transverse fracture shaft of the left femur. Patient 6's medical record was reviewed on 1/23/2022. a. The hospital discharge orders were reviewed. The discharging physician wrote orders for patient 6 to be on the following medications: (1) Aspirin 325 mg (milligrams) 1 tablet twice a day; (2) Flexeril 5 mg 1 tablet 3 times a day as needed for muscle spasms; (3) Alendronate 70 mg 1 tablet every week as needed; (4) Atorvastatin 40 mg 1 tablet at bedtime; (5) Gabapentin 400 mg 3 capsules at bedtime; (6) Levothyroxine 0.088 mg 1 tablet every day; (7) Morphine 15 mg 1 tablet every 12 hours; (8) Lidoderm 5% topical patch as needed; and (9) Oxydone 15 mg 1 tablet every 6 hours. The POC for the certification period dated 12/4/2021 to 2/1/2022 was reviewed. The POC had that patient 6 was to take "Oxycodone 5 mg every 1, 2, 4 and 6 hours..., Tylenol 8 hour every 1, 2, 6 and 8 hours..., and Dulcolax Bowel Cleansing 1 every day." (Note: No orders were given at the time of discharge for patient 6 to take the Tylenol or Dulcolax.) The rest of the medications listed above were not included in the POC. b. It was documented in an OASIS, dated 12/5/2021, that patient 6 had a surgical wound to the left lateral femur that had dressings in place. The SN documented that the surgical wound measured 4 cm (centimeters) X 1 cm X 1 cm on 12/1/2021. The surgical wound had a moderate amount of serosanguineous pink tissue with 80% granulation tissue. (Note: The measurement documented by the SN was when patient 6 was in the hospital.) The SN further documented, "Unable to remove dressing as per MD (medical doctor) instructions." The POC for the certification period of 12/4/2021 to 2/1/2022 was reviewed. The POC did include orders for the treatment of the surgical wound. On 2/23/2022 at 3:01 PM, a telephone interview was conducted with the administrator and the DON for the St. George area related to the medications and treatments that were not documented on the POC. The DON stated that it was the admitting nurse's responsibility to make sure that all medications and treatments were documented in the POC. The DON further stated that the admitting nurse should have contacted the discharging physician for clarifying orders related to the medications and the surgical wound care.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on interview and record review, it was determined for 1 of 7 sample patients, the agency staff did not provide care and services in accordance with physician orders. Specifically, aide visits were not completed as ordered. (Patient identifier: 1.) Findings include: Patient 1 was admitted to the agency on 1/15/2022 with diagnoses which included an autistic disorder and a cutaneous abscess of the abdominal wall. Patient 1's medical record was reviewed on 1/23/2022. The plan of care (POC) for the certification period of 1/15/2022 to 3/15/2022 was reviewed. The POC had orders that home health aides were to complete visits three times a week for five weeks. There were no home health aide visits completed the week of 1/16/2022 through 1/22/2022 and there were two missing home health aide visits the week of 1/13/2022 through 1/19/2022. No missed visit notes or any other documentation could be found to indicate why the missing visits were not completed. On 2/23/2022 at 4:13 PM, a telephone interview was conducted with the director of nursing (DON) for the Salt Lake (SL) area related to the missing home health aide visits. The DON stated that she believed the visits had been completed but not documented.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on interview and record review, the agency failed to ensure that skilled services were provided as necessary to meet the patient's needs for 1 of 7 sample patients. (Patient identifier: 1.) Findings include: The home health agency (HHA) failed to ensure clinical notes were accurately documented. (Refer to tag G0716).

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on interview, and record review, it was determined the home health agency did not ensure clinical notes were accurately prepared. Specifically, for 1 of 7 sample patients a skilled nurse (SN) and the director of nursing (DON) for the Salt Lake (SL) area changed nursing notes that were previously documented in such a way that the survey team was unable to determine who provided the cares and what cares were actually provided. (Patient identifier: 1.) Findings include: 1. Patient 1 was admitted to the agency on 1/15/2022 with diagnoses which included an autistic disorder and a cutaneous abscess of the abdominal wall. Patient 1's medical record was reviewed on 2/23/2022. The admitting nurse documented on the Outcome and Assessment Information Set (OASIS) assessment that homecare was needed for wound treatment due to an abdominal abscess with cellulitis. The nurse did not document the size or description of the wound. The nurse documented that the wound was cleaned with normal saline, applied a silver antibacterial ointment, covered with the wound with telfa and secured the dressing with tegaderm. On 1/17/2022, a physician's order was received to treat the abdominal abscess as follows, "Clean inside and surrounding wound with NS (normal saline) then betadine swabs. Apply colloidal silver. Cover with non-adherent dressing. Secure with tegaderm." a. The plan of care (POC) for the certification period of 1/15/2022 to 3/15/2022 was reviewed and copied on 2/23/2022 at 3:55 PM. It was documented on the POC that a home health aide was to assist patient 1 with personal care three times a week. The POC did not include wound care orders. The POC was again reviewed on 2/24/2022 at 12:15 PM. The POC had been changed to include the home health aide (HHA) frequency "Beginning 01/17/2022: HHA frequency: 3w (week) 5, 2w3, 1w1." Additionally, the following was added to the POC: (1) "SN to assess integumentary status, identify any signs and symptoms of impaired skin integrity, report significant changes to physician. (2) SN to instruct patient on disease process, including who to contact if signs and symptoms persist or worsen as well as dietary, hydration measures and medication management where indicated. (3) SN to perform wound care to ABD (abdominal) cellulitis abscess. Cleanse wound with NS then betadine, apply silver, cover with non-adherent dressing, and secure with tegaderm, using aseptic technique. SN may teach patient/caregiver to perform wound care. (4) SN indicated for wound care management based on physician orders due to the inherent complexity of the wound or no able/willing caregiver to perform wound care. (5) SN to instruct patient/caregiver on wound care performance and assess wound progression or decline." b. On 2/23/2022 at 4:29 PM, the SN visit note, dated 1/17/2022 was reviewed and copied. SN 1 documented that the wound to the left lower quadrant had a moderate amount of serosanguineous drainage and that the wound was "...cleansed with NS, applied silver antibacterial ointment, covered with telfa, secured with tegaderm..." The SN visit note was again reviewed on 2/24/2022 at 10:15 AM. The treating nurse no longer reflected that SN 1 completed the visit and that the DON of the SL area had completed the visit. Additionally, it was documented that the wound measured 5 cm (centimeters) X 3 cm and had a moderate amount of serosanguineous drainage. The treatment documented was changed to "SN cleansed with NS then betadine swabs, apply silver antibacterial ointment, covered with telfa, secured with tegaderm..." c. On 2/23/2022 at 4:29 PM, the SN visit note, dated 1/19/2022 was reviewed and copied. SN 1 documented that the wound to the left lower quadrant had a moderate amount of serosanguineous drainage and that the wound was "...cleansed with NS, applied silver antibacterial ointment, covered with telfa, secured with tegaderm..." The SN visit note was again reviewed on 2/24/2022 at 10:16 AM. The treating nurse no longer reflected that SN 1 completed the visit and that the DON of the SL area had completed the visit. Additionally, it was documented that the wound measured 5 cm X 3 cm and had a moderate amount of serosanguineous drainage. The treatment documented was changed to "SN cleansed with NS then betadine swabs, apply silver antibacterial ointment, covered with telfa, secured with tegaderm..." d. On 2/23/2022 at 4:36 PM, the SN visit note, dated 1/21/2022 was reviewed and copied. SN 1 documented that the wound to the left lower quadrant had a moderate amount of serosanguineous drainage and that the wound was "...cleansed with NS, applied silver antibacterial ointment, covered with telfa, secured with tegaderm..." The SN visit note was again reviewed on 2/24/2022 at 10:20 AM. The treating nurse no longer reflected that SN 1 completed the visit and that the DON of the SL area had completed the visit. Additionally, it was documented that the wound measured 4.5 cm X 3 cm and had a moderate amount of serosanguineous drainage. The treatment documented was changed to "SN cleansed with NS then betadine swabs, apply silver antibacterial ointment, covered with telfa, secured with tegaderm..." e. On 2/23/2022 at 4:37 PM, the SN visit note, dated 1/24/2022 was reviewed and copied. SN 1 documented that the wound to the left lower quadrant had a moderate amount of serosanguineous drainage and that the wound was "...cleansed with NS, applied silver antibacterial ointment, covered with telfa, secured with tegaderm..." The SN visit note was again reviewed on 2/24/2022 at 10:21 AM. The treating nurse no longer reflected that SN 1 completed the visit and that the DON of the SL area had completed the visit. The treatment documented was changed to "SN cleansed with NS then betadine swabs, apply silver antibacterial ointment, covered with telfa, secured with tegaderm..." f. On 2/23/2022 at 4:37 PM, the SN visit note, dated 1/26/2022 was reviewed and copied. SN 1 documented that the wound to the left lower quadrant had a moderate amount of serosanguineous drainage and that the wound was "...cleansed with NS, applied silver antibacterial ointment, covered with telfa, secured with tegaderm..." The SN visit note was again reviewed on 2/24/2022 at 10:22 AM. The treating nurse no longer reflected that SN 1 completed the visit and that the DON of the SL area had completed the visit. The treatment documented was changed to "SN cleansed with NS then betadine swabs, apply silver antibacterial ointment, covered with telfa, secured with tegaderm..." g. On 2/23/2022 at 4:37 PM, the SN visit note, dated 1/28/2022 was reviewed and copied. SN 1 documented that the wound to the left lower quadrant had a moderate amount of serosanguineous drainage and that the wound was "...cleansed with NS, applied silver antibacterial ointment, covered with telfa, secured with tegaderm..." The SN visit note was again reviewed on 2/24/2022 at 10:23 AM. The treating nurse no longer reflected that SN 1 completed the visit and that the DON of the SL area had completed the visit. Additionally, it was documented that the wound measured 4.5 cm X 2.75 cm and had a moderate amount of serosanguineous drainage. The treatment documented was changed to "SN cleansed with NS then betadine swabs, apply silver antibacterial ointment, covered with telfa, secured with tegaderm..." h. On 2/23/2022 at 4:38 PM, the SN visit note, dated 1/31/2022 was reviewed and copied. SN 1 documented that the wound to the left lower quadrant had a moderate amount of serosanguineous drainage and that the wound was "...cleansed with NS, applied silver antibacterial ointment, covered with telfa, secured with tegaderm..." The SN visit note was again reviewed on 2/24/2022 at 10:23 AM. The treating nurse no longer reflected that SN 1 completed the visit and that the DON of the SL area had completed the visit. The treatment documented was changed to "SN cleansed with NS then betadine swabs, apply silver antibacterial ointment, covered with telfa, secured with tegaderm." i. On 2/23/2022 at 4:38 PM, the SN visit note, dated 2/2/2022 was reviewed and copied. SN 1 documented that the wound to the left lower quadrant had a moderate amount of serosanguineous drainage and that the wound was "...cleansed with NS, applied silver antibacterial ointment, covered with telfa, secured with tegaderm..." The SN visit note was again reviewed on 2/24/2022 at 10:24 AM. The treating nurse no longer reflected that SN 1 completed the visit and that DON of the SL area had completed the visit. The treatment documented was changed to "SN cleansed with NS then betadine swabs, apply silver antibacterial ointment, covered with telfa, secured with tegaderm.. j. On 2/23/2022 at 4:38 PM, the SN visit note, dated 2/4/2022 was reviewed and copied. SN 1 documented that the wound to the left lower quadrant had a moderate amount of serosanguineous drainage and that the wound was "...cleansed with NS, applied silver antibacterial ointment, covered with telfa, secured with tegaderm..." The SN visit note was again reviewed on 2/24/2022 at 10:25 AM. The treating nurse no longer reflected that SN 1 completed the visit and that the DON of the SL area had completed the visit. Additionally, it was documented that the wound measured 4 cm X 2.5 cm and had a minimal amount of serosanguineous drainage without an odor. The treatment documented was changed to "SN cleansed with NS then betadine swabs, apply silver antibacterial ointment, covered with telfa, secured with tegaderm..." k. On 2/23/2022 at 4:39 PM, the SN visit note, dated 2/7/2022 was reviewed and copied. SN 1 documented that the wound to the left lower quadrant had a moderate amount of serosanguineous drainage and that the wound was "...cleansed with NS, applied silver antibacterial ointment, covered with telfa, secured with tegaderm..." The SN visit note was again reviewed on 2/24/2022 at 10:25 AM. The treating nurse no longer reflected that SN 1 completed the visit and that the DON of the SL area had completed the visit. Additionally, it was documented that the wound minimal amount of serosanguineous drainage without an odor. The treatment documented was changed to "SN cleansed with NS then betadine swabs, apply silver antibacterial ointment, covered with telfa, secured with tegaderm..." l. On 2/24/2022 at 4:39 PM, the SN visit note, dated 2/9/2022 was reviewed and copied. SN 1 documented that the wound to the left lower quadrant had a moderate amount of serosanguineous drainage and that the wound was "...cleansed with NS, applied silver antibacterial ointment, covered with telfa, secured with tegaderm..." The SN visit note was again reviewed on 2/24/2022 at 10:26 AM. The treating nurse no longer reflected that SN 1 completed the visit and that the DON of the SL area had completed the visit. Additionally, it was documented that the wound minimal amount of serosanguineous drainage without an odor. The treatment documented was changed to "SN cleansed with NS then betadine swabs, apply silver antibacterial ointment, covered with telfa, secured with tegaderm..." m. On 2/23/2022 at 4:39 PM, the SN visit note, dated 2/11/2022 was reviewed and copied. SN 1 documented that the wound to the left lower quadrant had a moderate amount of serosanguineous drainage and that the wound was "...cleansed with NS, applied silver antibacterial ointment, covered with telfa, secured with tegaderm..." The SN visit note was again reviewed on 2/24/2022 at 10:27 AM. The treating nurse no longer reflected that SN 1 completed the visit and that the DON of the SL area had completed the visit. Additionally, it was documented that the wound measured 3.5 cm X 2 cm and had a minimal amount of serosanguineous drainage without an odor. The treatment documented was changed to "SN cleansed with NS then betadine swabs, apply silver antibacterial ointment, covered with telfa, secured with tegaderm..." n. On 2/23/2022 at 4:40 PM, the SN visit note, dated 2/15/2022 was reviewed and copied. SN 1 documented that the wound to the left lower quadrant had a moderate amount of serosanguineous drainage and that the wound was "...cleansed with NS, applied silver antibacterial ointment, covered with telfa, secured with tegaderm..." The SN visit note was again reviewed on 2/24/2022 at 10:27 AM. The treating nurse no longer reflected that SN 1 completed the visit and that the DON of the SL area had completed the visit. Additionally, it was documented that the wound had no drainage or odor. The treatment documented was changed to "SN cleansed with NS then betadine swabs, apply silver antibacterial ointment, covered with telfa, secured with tegaderm..." o. On 2/23/2022 at 4:40 PM, the SN visit note, dated 2/17/2022 was reviewed and copied. SN 1 documented that the wound to the left lower quadrant had a moderate amount of serosanguineous drainage and that the wound was "...cleansed with NS, applied silver antibacterial ointment, covered with telfa, secured with tegaderm..." The SN visit note was again reviewed on 2/24/2022 at 10:28 AM. The treating nurse no longer reflected that SN 1 completed the visit and that the DON of the SL area had completed the visit. Additionally, it was documented that the wound measured 3 cm X 2 cm and had no drainage or odor. The treatment documented was changed to "SN cleansed with NS then betadine swabs, apply silver antibacterial ointment, covered with telfa, secured with tegaderm..." p. On 2/23/2022 at 4:40 PM, the SN visit note, dated 2/21/2022 was reviewed and copied. SN 1 documented that the wound to the left lower quadrant had a moderate amount of serosanguineous drainage and that the wound was "...cleansed with NS, applied silver antibacterial ointment, covered with telfa, secured with tegaderm..." The SN visit note was again reviewed on 2/24/2022 at 10:29 AM. The treating nurse no longer reflected that SN 1 completed the visit and that the DON of the SL area had completed the visit. Additionally, it was documented that the wound had no drainage or odor. The treatment documented was changed to "SN cleansed with NS then betadine swabs, apply silver antibacterial ointment, covered with telfa, secured with tegaderm..." 2. On 2/24/2022 at 10:34 AM, a telephone call was placed to the DON of the SL area. The DON was asked about the changed SN visit notes. The DON stated that she had SN 1 correct everything to include the use of the betadine as well as wound measurements. The DON stated that SN 1 had a separate notebook with which he documented measurements. The DON was further asked why SN 1 no longer showed as the treating nurse. The DON stated she did not know why. 3. On 2/24/2022 at 10:40 AM, a telephone call was placed to SN 1. SN 1 stated that visit notes were changed by him and the DON of the SL area. SN 1 stated that the visit notes were changed based off the documentation he had in a separate notebook. SN 1 was asked to provide a copy of the visit notes that were documented in the notebook. On 2/24/2022 at 3:34 PM, SN 1 provided documentation of wound measurements for 5 of 7 visit notes that were changed to reflect wound measurements. Additionally, the documentation in the notebook included the depth of the wound which were not included in the changed visit notes. 4. On 2/24/2022 at 11:20 AM, a telephone interview was conducted with the administrator, the DON of the St. George area and the DON of the SL area. The staff were asked what the process was for documenting changes to the medical record after the visits were completed. The DON of the St. George area stated that a communication note should have been completed to explain why the visit notes were changed.

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based on interview and medical record review, it was determined the home health agency did not maintain clinical records which contained pertinent past and current findings in accordance with accepted professional standards. Specifically, skilled nursing (SN) visit notes were changed to include the ordered treatment, wound measurements, a description of the wound as well as who the treating nurse was which resulted in conflicting information for 1 of 7 patient records reviewed. (Patient identifier: 1) Findings include: 1. Patient 1 was admitted to the agency on 1/15/2022 with diagnoses which included an autistic disorder and a cutaneous abscess of the abdominal wall. Patient 1's medical record was reviewed on 2/23/2022. a. The admitting nurse documented on the Outcome and Assessment Information Set (OASIS) assessment that homecare was needed for wound treatment due to an abdominal abscess with cellulitis. The nurse did not document the size or description of the wound. The nurse documented that the wound was cleaned with normal saline, applied a silver antibacterial ointment, covered with the wound with telfa and secured the dressing with tegaderm. The POC was not authenticated by the nurse that created it. The POC was again reviewed on 2/24/2022 at 12:15 PM. The POC had been changed to include the home health aide (HHA) frequency "Beginning 01/17/2022: HHA frequency: 3w (week) 5, 2w3, 1w1." Additionally, interventions were added to the POC, but did not include when the interventions were implemented. b. The SN visits that occurred between 1/17/2022 to 2/21/2022 were reviewed. SN 1 documented in all the visit notes, that the wound to the left lower quadrant had a moderate amount of serosanguineous drainage and that the wound was "...cleansed with NS, applied silver antibacterial ointment, covered with telfa, secured with tegaderm..." The visit notes did not contain measurements of the wound to determine if the wound was getting better, worse or was unchanged. On 2/23/2022 at 4:13 PM, a telephone interview with conducted with the director of nursing (DON) of the Salt Lake (SL) area. The DON was asked why the POC did not include treatment orders and why measurements of the wound were not documented in the skilled nursing visits. The DON stated that she did not know why the treatment orders did not "pull" over to the POC and that she would contact SN 1 and return a call to the surveyor on 2/24/2022. c. The SN visit notes that occurred between 1/17/2021 to 2/21/2022 were reviewed again on 2/24/2022. The visit notes no longer reflected that SN 1 completed the visits and that the DON of the SL area had. Additionally, the wound treatments were changed to "SN cleansed with NS then betadine swabs, apply silver antibacterial ointment, covered with telfa, secured with tegaderm..." The visit notes for 1/17/2022, 1/19/2022, 1/21/2022, 1/28/2022, 2/4/2022, 2/11/2022 and 2/17/2022 were changed to include measurements of the wound. The visit notes for 2/4/2022, 2/7/2022, 2/9/2022, 2/11/2022, 2/15/2022, 2/17/2022 and 2/21/2022 had the description of the wound changed which included drainage, how much drainage and whether an odor was present was. 2. On 2/24/2022 at 10:34 AM, a telephone call was placed to the DON of the SL area. The DON was asked about the changed SN visit notes. The DON stated that she had SN 1 correct everything to include the use of the betadine as well as wound measurements. The DON stated that SN 1 had a separate notebook with which he documented measurements. The DON was further asked why SN 1 no longer showed as the treating nurse. The DON stated she did not know why. 3. On 2/24/2022 at 10:40 AM, a telephone call was placed to SN 1. SN 1 stated that visit notes were changed by him and the DON of the SL area. SN 1 stated that the visit notes were changed based off the documentation he had in a separate notebook. SN 1 was asked to provide a copy of the visit notes that were documented in the notebook. On 2/24/2022 at 3:34 PM, SN 1 provided documentation of wound measurements for 5 of 7 visit notes that were changed to reflect wound measurements. Additionally, the documentation in the notebook included the depth of the wound which were not included in the changed visit notes. 4. On 2/24/2022 at 11:20 AM, a telephone interview was conducted with the administrator, the DON of the St. George area and the DON of the SL area. The staff were asked what the process was for documenting changes to the medical record after the visits were completed. The DON of the St. George area stated that a communication note should have been completed to explain why the visit notes were changed.