Agawam East Rehab And Nursing

P.M. shift left blank-07/11/25 coded as 14Monitor Discoloration to Bilateral Lower Arms-07/01/25 7:00 A.M.-3:00 P.M. shift left blank-07/05/25 and 07/11/25 coded as 14

During an interview on 09/02/25 at 12:30 P.M., (which included review of Resident #1's June and July 2025 TARs with the surveyor), Nurse #1 said when nursing administers a treatment, they should sign it off as being completed, and if there were blank spaces on the TAR, that meant that nursing did not complete their documentation.

Nurse #1 also reviewed the last page of the TAR, with the surveyor, which included a key to the various charting codes.

Nurse #1 said code 14 indicated Behavior not observed and said she did not know why she chose that code when she documented Resident #1's treatments.

Nurse #1 said she could not recall if she administered treatments on those days or if Resident #1 refused the treatments.

During an interview on 09/02/25 at 3:20 P.M., (which included review of Resident #1's June and July 2025 TARs with the surveyor), Unit Manager #1 said a code of 14 indicated that a behavior was not observed.

Unit Manager #1 said if a resident refused a medication or treatment, nursing should document the refusal by using the number 2 with indicated drug refused.Review of Resident #1's June 2025 Documentation Survey Report (ADL Flow Sheets) for 06/07/25 through 06/30/25 indicated for the following shifts, CNA documentation for turning and repositioning, and applying barrier cream was incomplete and left blank.- 3:00 P.M.-11:00 P.M. shift: one day (out of 24) was left blank.- 11:00 P.M.-7:00 A.M. shift: 15 days (out of 24) were left blank.Review of Resident #1's July 2025 ADL Flow Sheets for 07/01/25 through 07/13/25 indicated for the following shifts, CNA documentation for turning and repositioning, and applying barrier cream was incomplete and left blank:- 11:00 P.M.-7:00 A.M. shift: six days (out of 12) were left blank.

During an interview on 09/02/25 at 2:00 P.M., CNA #1 said CNAs are supposed to document throughout their shift and make sure to have all their documentation completed by the end of their shift. CNA #1 said if there are blank spaces on the ADL Flow Sheet, that meant the CNA documentation was not completed.

During an interview on 09/02/25 at 2:40 P.M., CNA #2 said all their documentation must be completed in the computer by the end of the shift.

During an interview on 09/02/25 at 2:55 P.M., CNA #3 said all CNA documentation is to be done in the computer, and it must be completed by the end of their shift. CNA #3 said if the CNA Flow Sheet has blank spaces, a resident may have refused care, but if the resident refused care, the CNAs were supposed to code that a resident refused, not leave it blank.

During an interview on 09/02/25 at 3:20 P.M., Unit Manager #1 said all CNA documentation is recorded in the electronic health record, and the expectation is they have it completed by the end of their shift.

After reviewing the ADL Flow Sheets with the surveyor, Unit Manager #1 said if there were blank spaces, which meant that the documentation was not completed, as required.

During an interview on 09/02/25 at 4:10 P.M., the Director of Nursing (DON) said nurses and CNAs are required to complete documentation in the electronic health record by the end of their shift.

The DON said if there were blank spaces on the TARs and CNA Flow Sheets, that indicated that documentation was not completed, as required.After reviewing Resident #1's TARs with the surveyor, the DON said the Code 14 indicated a behavior was not observed and that code should not be used for any documentation other than for behavior monitoring.

The DON said it was inappropriate for Nurse #1 to use code 14 when documenting skin treatments and interventions.

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