Failure to Provide Individualized Activities Program for Resident
Summary
The facility failed to provide an ongoing, individualized, and meaningful activities program for a resident, identified as R11, who was reviewed for activities. R11, who is bed-bound and legally blind, reported feeling bored with nothing to do but watch TV in their room. The facility did not complete an assessment of activity goals for R11, and no plan of care related to activities was developed. The facility's policy requires that each resident's interests and needs be assessed routinely, and activities should be designed to enhance well-being and reflect the resident's interests and preferences. R11 was admitted to the facility with multiple diagnoses, including multiple sclerosis, a fracture of the neck of the right femur, muscle weakness, unspecified dementia, neuromuscular dysfunction of the bladder, and legal blindness. The Minimum Data Set (MDS) assessment indicated severe cognitive impairment and highly impaired vision. Despite these conditions, the facility did not conduct an activity assessment to understand R11's preferences or goals. The surveyor noted that the facility's activity staff occasionally offered mobile carts with puzzles, books, games, and crafts, but these were not suitable for R11's condition. Additionally, there were no audio books available, and the staff did not document whether activities were offered and refused. The surveyor found that R11's plan of care lacked any information related to activities, indicating a failure to provide individualized and meaningful activities for R11. The facility's activity evaluation forms, which should have been completed within four days of admission and during subsequent assessments, were found to be incomplete. The surveyor shared these concerns with the facility consultants, who acknowledged the lack of an activity assessment and plan of care for R11. No additional information was provided to explain why the facility did not meet the requirements for an individualized activities program for R11.
Penalty
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A resident with cerebral palsy, profound intellectual disabilities, severe cognitive impairment, and total dependence for ADLs had a care plan calling for individualized, cognitively stimulating, and social activities, including room visits two to four times weekly and adapted activities based on assessed needs and preferences. Over several months, activity documentation showed only sporadic hand massages, occasional time sitting in a common living room, brief room visits, a single holiday party, and one instance of listening to music, with no evidence of consistent, care-planned programming. Surveyor observations twice found the resident sitting in front of a television in a common area without staff interaction. The AD confirmed that records did not support that the resident was offered or provided activities as outlined in the care plan, despite a facility policy requiring an ongoing, individualized activity program.
A resident with Alzheimer's disease, major depressive disorder, ataxia, severe cognitive impairment, and dependence in ADLs had documented preferences for music, social interaction, and favorite activities, and a care plan allowing participation in group and 1:1 activities as tolerated. Despite this, there was no evidence in the medical record or 1:1 activity lists that she received 1:1 visits, and she reported that activity staff did not visit her room. She remained in bed with the TV out of her view and had only one documented activity offer related to a holiday event, while both the AD and an activity assistant confirmed she was not included on their 1:1 visit lists, contrary to the facility’s activities program policy.
The facility failed to provide and document evening activities for several cognitively impaired residents whose care plans identified specific activity interests and needs for assistance and verbal prompts. Activity records over a month showed no participation documented after 4:30 p.m., even though the activity calendar listed afternoon and evening programs such as nail care, snacks/hydration, sensory boxes, and movie and snack sessions in the memory care unit. Observations revealed that scheduled activities were not occurring at the designated times, and staff acknowledged that activities were not completed as planned and that documentation after 4:30 p.m. was not monitored, despite policy assigning responsibility for maintaining individual participation records to the activity coordinator.
Surveyors found that the facility failed to provide and document activities according to individual resident preferences and did not make activity assessments accessible to staff. One resident with COPD and bipolar disorder had no evidence of being invited to group activities and was repeatedly observed in bed or in a hallway without entertainment despite scheduled crafts in common areas. Another cognitively intact resident with multiple chronic conditions received only in-room visits and no community outings, even though she stated she would love to go out to eat or shop, and activity calendars showed no community activities. A resident with vascular dementia, whose care plan called for independent activities like music, word searches, and church services, was repeatedly observed in her room without any preferred items, and activity staff reported providing no activities for her that week. A resident with psychiatric and cognitive disorders, whose care plan listed bingo, dancing, singing, math problems, and going outside as preferred activities and specifically noted a dislike of coloring, was instead predominantly offered coloring, crafts, and generic "chit chat," with inconsistent one-on-one documentation and no records of the preferred activities being provided. Staff and the administrator confirmed lack of access to activity evaluations, inconsistent activity logs, and absence of community activities, despite a policy requiring programs to reflect residents’ individual needs and preferences.
Surveyors found that the facility failed to provide adequate, individualized activities and sufficient activity staffing. Resident council minutes and staff and resident interviews described activities being cut short, loss of live entertainment and in-person religious services, and use of activity staff for non-activity tasks such as snack passing and obtaining menu selections. Activity calendars showed limited variety, no separate programming for cognitively impaired residents, and very few one-on-one or independent activities. Observations during a bingo session showed several cognitively impaired residents present without needed assistance or meaningful participation. Records for two residents with dementia, anxiety, and mobility issues showed care plans calling for daily 1:1 room visits by activity staff, but there was no documentation that these visits occurred over several months, despite a facility policy stating that activities should reflect residents’ cultural and religious interests and be tailored with appropriate accommodations.
Two residents on a secured unit did not receive meaningful or preferred activities despite documented preferences and care plan directives. One cognitively intact resident with dementia and depression had care plan goals to participate in music, religious services, socialization, and other leisure pursuits, yet records showed minimal participation beyond some food events and bingo, and observations found the resident in common areas without structured or independent activities. Another resident, who was legally blind with communication and mobility deficits, had documented preferences for music and news, but activity logs showed almost no provision of these, and observations over several days found the resident in a recliner or in bed with no music or TV playing. Staff interviews confirmed there was no dedicated activity staff on the secured unit, activity staff did not routinely go there, only a few residents were occasionally brought off the unit for activities, and there were no daily, structured activities despite a policy requiring accommodation of resident activity preferences.
Failure to Provide Care-Planned, Individualized Activities for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide activities that met a resident’s assessed needs, preferences, and cognitive capabilities. The resident had cerebral palsy, profound intellectual disabilities, seizures, hypertension, and dysphagia, with an MDS showing severe cognitive impairment and total dependence on staff for ADLs. The care plan dated 01/23/24 documented that the resident was dependent on staff for emotional, physical, spiritual, creative, and community activities, with goals to maintain involvement in cognitive stimulation and social activities and to participate in room visit programming two to four times weekly. Interventions included inviting the resident to scheduled activities, ensuring activities were compatible with physical and mental capacities and adapted as needed, and monitoring room visits and providing sensory-stimulating interventions. Activity documentation from January through March 2026 showed limited and infrequent activities for the resident, consisting mainly of occasional hand massages, being up in the living room, room visits, small chats, and one Valentine’s Day party and one instance of listening to music in the room. No other activities were documented beyond these few entries in each month. Observations on two separate days in March showed the resident sitting in a common area in front of a television, with no staff interaction noted and, at one time, no staff present while the resident and others watched television. In an interview, the Activity Director confirmed that the documentation from January to early March 2026 did not support that the resident was offered or provided activities as care planned for the resident’s preferences and needs, and that activities provided on some days were limited to being up in the living room, in the room with music on the television, and hand massages. This was inconsistent with the facility’s activity policy requiring an ongoing program based on each resident’s comprehensive assessment, care plan, and preferences.
Plan Of Correction
F0679 activities The POC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident # 40 has a new activities plan based on her particular needs utilizing the comprehensive assessment , care plan and preferences were done on 3-18-26 by the activities director. The new activities plan was created by the activities director on 3-18-26. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. Residents identified with similar cognitive and physical delays have been screened for appropriate activity plans. Residents who are identified with intellectual disabilities by diagnosis or low BIM scores and have community and individual activities ongoing to meet their needs. Sweep done 3-19-26. The activity director did the sweep and there were no negative concerns during the sweep. What measures will be put into place, or what systemic changes you will make to ensure that the deficient practice does not recur. The activities director was educated on 3-17-26 by administrator that the facility has an on-going program to support residents in their choice of activities, both facility sponsored groups and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community considering the residents level of functioning. How the corrective action will be monitored to ensure the deficient practice will not recur. Audits of proper activities began 3-19-26 The administrator/designee is auditing for activities that meet the needs of the residents with cognitive and intellectual delays, utilizing proper activity programming weekly X 4 weeks. Results being submitted to the QAPI committee. Concerns identified from the audit will be addressed, and the activity director will be further directed in proper activities by the administrator or classes.
Failure to Provide Individualized 1:1 Activities for Bedbound Resident
Penalty
Summary
The facility failed to provide individualized activities of interest to a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, major depressive disorder, and ataxia. The resident’s annual MDS assessment documented severe cognitive impairment, dependence in ADLs, and that music, doing things with other people, and engaging in favorite activities were important to her. An activity preference assessment indicated she enjoys talking. The resident’s care plan stated she may continue to participate in group and/or 1:1 activities of her choice as tolerated. However, review of the medical record showed no evidence that she participated in 1:1 visits, and the activity department’s 1:1 list did not include her. During observation, the resident was found lying in bed with the bed against the wall and the TV positioned on the opposite wall, out of her view. She reported that activity staff do not visit her in her room. The Activity Director stated that activities are documented in the electronic chart and that she conducts 1:1 visits two to three times per week, and acknowledged that the resident had previously attended bingo but had been staying in bed due to pain in recent weeks. The Activity Director further revealed that activities staff did not conduct 1:1 visits with the resident while she was staying in her room, and there was no documentation that she was offered activities except for a Valentine’s Day celebration. The Activity Assistant confirmed she kept her own list of residents receiving 1:1 visits and verified that this resident was not on her list. The facility’s undated Activities Program policy stated that the facility will provide resident-centered care that meets the psychological, physical, and emotional needs and concerns of residents.
Failure to Provide and Document Evening Activities for Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document resident activities during evening hours, particularly after 4:30 p.m., for residents with impaired cognition. Three residents with dementia or cognitive impairment had care plans and activity assessments identifying interests such as reading, watching television, being outdoors, socializing, and participating in group programs. Their plans of care included interventions like providing activity calendars, assisting and escorting to activities, offering materials for individual activities, and encouraging participation in groups. However, review of their electronic health records over a one‑month period showed no documented activity participation after 4:30 p.m. Surveyors also found that scheduled activities in the memory care unit were not consistently carried out as planned. The March activity calendar listed nail care and snacks/hydration in the afternoon, and repeated evening activities such as sensory boxes and movie and snack sessions. Observations showed that a scheduled nail care activity was not in progress at the designated time, and the snack and hydration activity was not completed as scheduled. Activity staff reported that only two activity staff worked and they left by 4:30 p.m. daily, and that floor staff on the memory care unit were assigned to complete and document evening activities. The Activity Director confirmed that activity participation documentation was silent after 4:30 p.m., that the scheduled activities were not followed on a specific date, and that she did not monitor charting to ensure staff documented resident participation, despite facility policy stating that the activity coordinator maintains individual participation records.
Failure to Provide and Document Resident-Preferred Activities and Community Outings
Penalty
Summary
The deficiency involves the facility’s failure to provide activities that met individual residents’ assessed needs and preferences, and to make those preferences accessible to staff. For one resident admitted with COPD, bipolar disorder, alcohol dependence, and hypertension, the admission activity assessment documented that he did not respond to questions and there was no evidence that family was contacted to obtain preferences. His care conference indicated activity staff were to offer group activities and review the monthly calendar, yet activity documentation from admission through the first week showed only a single one-on-one “chatting” interaction by a nurse aide and no evidence he had been invited to group activities. Multiple observations over several days showed this resident either in bed or in a wheelchair in the hallway with no entertainment, even when craft activities were occurring in common areas. Activity staff later stated they were unable to document any activities for him and had no evidence he had participated in or been invited to activities since admission. Another resident, cognitively intact and with multiple chronic conditions including chronic respiratory failure, morbid obesity, COPD, sleep apnea, and several psychiatric diagnoses, was assessed as preferring room visits three times per week and not wanting to participate in activities outside her room. However, the assessment did not document that she was asked about interest in community activities. Activity logs over a three‑month period showed no activities outside her room and no community activities. Observations on several dates showed her lying in bed with no staff approaching to ask about activity participation. In interview, she confirmed that no community activities were offered and stated she would love to go out to eat or go shopping but that this was never offered. Activity staff confirmed they did not have access to residents’ activity assessments, were unsure of individual preferences unless residents told them directly, and that no community activities were scheduled; review of facility activity calendars over three months showed no community activities. A third resident with vascular dementia, anxiety disorder, and muscle weakness had an activity assessment and care plan indicating she did not wish to participate in group activities but preferred independent activities such as listening to music, doing word searches, attending church services, and receiving music, word search books, and crafting supplies. Observations over two days at multiple times showed her sitting in her room without any of her preferred independent activity items provided. Activity staff interviews revealed that one‑on‑one documentation was kept on paper in a book held by the activity coordinator, that individual preferences were obtained from the Activity Director or by learning from staff and residents, and that no activities had been provided for this resident during the week. A fourth resident with major depressive disorder, generalized anxiety disorder, schizoaffective disorder (including bipolar type), dementia, and restlessness/agitation had a care plan directing staff to encourage attendance at activities of interest and to provide preferred activities such as bingo, dancing, singing, writing and solving math problems, and going outside, while noting that the resident did not like coloring or drawing. Observations over two days showed this resident in their room with the door shut and not participating in activities while other residents in the common room engaged in coloring and drawing. Review of the resident’s activity task documentation over 30 days showed that activities offered were predominantly coloring, crafts, “chit chat,” or art, with participation often passive or refused. A 90‑day review of one‑on‑one activity documentation showed activities were not consistently offered and often recorded generic entries such as the resident being out of the room or “morning news,” with no entries for bingo, music, dancing, or outdoor activities. Activity staff reported that if residents did not want group activities they would offer one‑on‑one interactions such as talking or hand massages, that this resident struggled with group activities and was given one‑on‑ones, and that they identified music and talking as interests. Staff also confirmed they lacked access to residents’ activity evaluations, used paper tracking for some one‑on‑ones, and that community activities were not being conducted. The facility’s Activity Programs policy stated that programs are to be geared to individual needs and reflect residents’ schedules, choices, rights, interests, hobbies, and personal preferences, which was not supported by the documented practices and observations. The Administrator confirmed that the facility did not have consistent activity logs to verify when activities occurred and which residents participated. Activity staff further confirmed that they did not have access to residents’ activity evaluations to identify preferences and that some one‑on‑one activities were tracked only on paper for certain residents. Across the four residents reviewed, surveyors found a pattern of missing or incomplete assessment follow‑through, lack of documented invitations to activities, absence of preferred or community activities, and reliance on limited or generic activities such as coloring and crafts that did not align with documented or expressed preferences. These findings demonstrated that the facility failed to ensure activity preferences were available to aides and failed to complete activities according to resident preferences, contrary to its own Activity Programs policy.
Failure to Provide Adequate, Individualized Activities and Sufficient Activity Staffing
Penalty
Summary
The deficiency involves the facility’s failure to provide activities that met all residents’ needs and to maintain adequate activity staffing. Resident Council minutes documented residents reporting that activities were being cut short due to insufficient staff and that live musical entertainers were no longer provided. The Administrator responded that activities were not being shortened because of staffing and explained that entertainers were now required to have a tax identification number to be issued a 1099, and that no entertainers were willing to comply. Review of activity calendars for several months showed only one facility-wide calendar with no separate programming for residents with cognitive impairments, limited variety in scheduled activities, and very few one-on-one or independent activities/room visits. Activities were largely repetitive, consisting of daily coffee and discussion with distribution of the Daily Chronicle, weekly Bible study and church services, and bingo three times per week. Interviews and observations showed that activity staff were being used for non-activity tasks and that residents with higher needs were discouraged from attending group activities. An activities staff member reported that the facility previously had pastors come in for Sunday services but now relied on televised services, and a resident expressed a desire for more religious services, particularly Catholic, stating that television services were not interactive. Observations showed an activities assistant hurriedly delivering the Daily Chronicle with minimal interaction and later spending nearly two hours going room to room obtaining menu selections for the next day’s meals. Multiple residents and staff reported that the activities department lacked sufficient staff, that one activity aide was routinely diverted to pass snacks and obtain menus, and that staff had been told by the Administrator not to bring residents to group activities if they needed help, as it was considered unfair to other residents. Anonymous employees stated that residents who were not cognitively intact or were significantly disabled were not to attend activities like bingo if they could not participate independently, and that in-person religious services had not occurred for approximately two months. Specific residents’ records and observations further demonstrated unmet activity needs. One resident with severe dementia, anxiety, depression, insomnia, and impaired mobility had a care plan calling for daily one-on-one room visits by activity staff to promote socialization and reduce boredom, but electronic records for three consecutive months showed no documentation that these visits occurred. Another resident with moderate dementia, anxiety, difficulty walking, and anorexia had a similar care plan for daily one-on-one room visits, also without any documented completion over the same three-month period. During a bingo activity observed with about 20 participants, two activity assistants were present, but one resident sat with eyes closed and no active participation despite having a bingo card and chips, and two cognitively impaired residents were seated without adequate assistance; one was not given a bingo card or chips and continuously chewed on a blanket, and another could not follow the game despite having a card and chips. An employee reported that there was room for improvement in activities, that there were not enough activities, residents were bored, and residents felt their activity suggestions were not being considered. These findings contrasted with the facility’s written activities policy, which stated that activities would reflect residents’ cultural and religious interests and be person-appropriate, with accommodations in schedules, supplies, and timing to optimize participation.
Failure to Provide Meaningful and Preferred Activities on Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to provide meaningful and preferred activities for residents on the secured unit, specifically for Resident #9 and Resident #11, despite identified preferences and care plan interventions. Resident #9, admitted with dementia, major depressive disorder, anxiety, and other medical conditions, had a BIMS score indicating intact cognition and a care plan stating the resident felt it was important to listen to music, be around animals, watch TV, play bingo, socialize, go outside in good weather, and attend religious services. The care plan directed staff to invite, encourage, and assist the resident to activities of interest and to provide supplies for independent leisure activities. Activity calendars showed that music, religious services, food activities, and bingo were regularly scheduled, but participation records for December showed Resident #9 did not attend any music or religious activities, only some food and bingo events, and observations during survey showed the resident in common areas without involvement in any structured or independent activity. Interviews with staff confirmed that the secured unit did not have an assigned activity person and that activity staff did not go to the secured unit to conduct activities. The Activity Coordinator stated that only three or four residents who could sit for 15 to 30 minutes were brought off the secured unit for activities, and verified that residents on the secured unit did not participate in certain scheduled activities such as bread day, although bread was passed to them. The Program Director for the secured unit stated that “Social Circle” on the activity log could mean puzzles, crafts, coloring, or other various activities, and that movies and watching TV were considered the same activity. The Program Director further stated that music was played during meals and the TV was on the rest of the time, and that these were considered daily activities for Resident #9, along with talking and interaction in common areas. However, the Program Director also verified there were no daily, structured activities on the secured unit and that nursing staff only did activities when able. For Resident #11, who was legally blind with a cognitive communication deficit, difficulty walking, and high blood pressure, the activity care plan documented that it was important to him to listen to music, keep up with the news, participate in group activities, go outside, attend religious services, and have snacks between meals. Review of daily activity logs over several weeks showed that the only documented music exposure occurred when musical entertainment performed at the facility, and there was only one entry for crafts, with no entries indicating that the resident listened to music or kept up with the news as preferred. Multiple observations over several days found Resident #11 lying or sitting in a recliner in a common area near the front desk and main entrance, or resting in bed, without music or TV playing. The Activity Coordinator confirmed that the resident had been seated in the common area for the past two days with no music or news playing, despite these being documented as important activity choices for him. The facility’s policy on Resident Activity Preferences stated that the facility would accommodate resident activity preferences through the comprehensive assessment and care planning process, which was not followed in these cases.
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