Deficiency in Resident Activities and Outdoor Access
Summary
The facility failed to provide engaging activities for residents, as evidenced by the case of a resident who was observed in bed without stimulation and expressed interest in more independent and one-on-one activities. Despite the resident's care plan indicating a need to break the cycle of inactivity and establish a list of enjoyable activities, the Activities Director was unaware of these interventions and did not track participation or refusals. The resident's interest in music and audio books was not adequately addressed, and there were no specific interventions in the care plan to support these preferences. Multiple residents on Unit B expressed a desire to spend time outdoors, but the facility did not support this interest. Record reviews and interviews revealed that residents had preferences for outdoor activities, but their care plans lacked specific interventions to facilitate this. The Activities Director acknowledged the issue of limited outdoor access and insufficient staffing to accommodate residents' preferences, with only three outdoor activities scheduled over two months. The facility also failed to provide weekend activities, as observed on a Sunday when no activities took place on Unit B. The activity calendars for July and August showed no scheduled activities on weekends, and the Activities Director confirmed that the department was short-staffed, making it difficult to maintain the activities program. The SCU Unit Manager noted that nursing staff attempted to provide activities when none were scheduled, but there was no consistent presence in the dining room to engage residents.
Penalty
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Multiple residents with dementia and severe cognitive impairment did not receive individualized activity programming despite documented preferences for music, religious services, social events, outdoor time, and specific leisure interests. MDS assessments and activity assessments identified what was very important to these residents, but CAAs did not trigger, care plans lacked instructions for preferred activities, and EMR review showed only a single documented group music activity over a month. A scheduled hand and nail spa activity on the memory unit did not occur as posted; instead, residents were observed resting, sitting, or wandering without the planned activity, while staff reported that there were few activities on the unit and that turning on the TV or passing out snacks was treated as activity. This practice conflicted with the facility’s policy that the Activity Department provide a program supporting residents’ self-esteem, well-being, and satisfaction with an active lifestyle.
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 intact cognition and a history of active participation in group activities, Resident Council, and church sustained bilateral lower-extremity fractures and returned from the hospital non–weight bearing. The MDS significant change assessment and the activity care plan documented that group involvement, church services, and various preferred activities were important to the resident, yet no new interventions were added to the care plan after the change in condition. Activity participation records showed that the resident had no out-of-room activities and only two documented 1:1 visits, while the Director of Recreation acknowledged that group attendance had stopped and that in-room social visits were not consistently documented. The resident reported feeling unable to attend her usual groups, Resident Council, or church and stated that activity staff did not visit often, leading surveyors to find that the facility failed to provide an activities program that met her needs and interests following her significant change.
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.
Surveyors found that the facility did not complete activity assessments or develop care plan interventions for multiple residents with conditions such as dementia, bipolar disorder, stroke, MS, and schizophrenia, despite a policy requiring individualized activity programming. An outdated activity calendar was posted, but no group activities were observed over several days, and several cognitively intact residents reported that there were not enough activities, that they were bored, and that activity staff were insufficient. Some residents described doing nothing all day except for medical appointments or paying out-of-pocket for outings. Records for residents identified as needing 1:1 activities showed they were scheduled on specific days, yet there was no documentation of 1:1 activities being offered or provided, and observations confirmed these residents were not engaged in such activities. The Activity Director stated she had just started employment and had not yet created a current calendar or begun 1:1 activities, while the Administrator and DON stated they expected activities and 1:1 services to be provided and reflected in care plans.
Facility staff did not consistently provide or document weekly 1:1 activity sessions for a bed-bound, cognitively intact resident with significant physical limitations and multiple medical conditions, despite a care plan requiring staff-dependent activities, cognitive stimulation, and social interaction. Documentation over a one-month period showed only two 1:1 sessions and a few brief social contacts that did not reflect structured activities as care planned. The activities calendar was posted but not effectively communicated, as the resident reported not knowing it was in the room or understanding the activities process and learning of at least one event only from a CNA. The Activities Director and DON stated that residents unable to attend group activities should receive weekly bedside or 1:1 activities and reminders about scheduled events, but records did not demonstrate that this occurred for the resident.
Failure to Provide Resident-Specific Activities on Memory Unit
Penalty
Summary
The deficiency involves the facility’s failure to provide resident-specific activity programs for multiple residents with dementia or severe cognitive impairment on the memory unit. For several residents, including those with diagnoses of dementia and Alzheimer’s disease, the Minimum Data Set (MDS) assessments documented severe cognitive impairment, with Brief Interview for Mental Status (BIMS) scores of 99 or staff assessments indicating severe impairment. These assessments also documented that it was very important to the residents to listen to preferred music, participate in favorite activities and religious services, and go outside for fresh air when the weather was good. Despite these documented preferences, the Activity Care Area Assessments (CAAs) did not trigger for these residents, and their care plans lacked staff instructions regarding their preferred activities. For each of the identified residents, the facility’s records showed minimal or no documented participation in activities over a one-month review period. Electronic Medical Record (EMR) review for the residents showed that each participated in only one documented activity, a music program on a single date, with no other activities recorded from early March through early April. Activity Assessments completed for these residents identified specific interests such as church services, parties, visiting with others, watching westerns or baseball on TV, listening to country music or other music, going for walks, being around animals, and going outside in good weather. However, these preferences were not reflected in individualized care plan instructions, and there was no documentation that these preferred activities were being provided on an ongoing basis. Surveyor observations and staff interviews further demonstrated that scheduled activities on the memory unit were not carried out as planned. The posted Activity Calendar listed an "Afternoon Hand and Nail Spa" at a specified time, but at that time residents were observed resting in bed, sitting in recliners with eyes closed, sitting at the dining room table, or wandering the unit, with no hand and nail spa activity occurring. A CNA confirmed that the fingernail activity did not take place and that staff instead handed out snacks, and stated she did not know why the scheduled activity was not provided. Activity staff reported that unit staff were responsible for conducting activities on the memory unit, while CNAs and a nurse indicated that there were not many activities on the unit and that staff mainly ensured the TV was on or passed out snacks, which they considered “somewhat of an activity.” An administrative nurse stated that the activity staff planned the activities and that nurses on the memory unit were responsible for executing and documenting them, but the facility’s own policy required the Activity Department to provide an activity program that supports positive self-esteem, well-being, and satisfaction with the facility’s active lifestyle, which was not reflected in practice for these residents. Title: Failure to Provide Resident-Specific Activities on Memory Unit ShortSummary: Multiple residents with dementia and severe cognitive impairment did not receive individualized activity programming despite documented preferences for music, religious services, social events, outdoor time, and specific leisure interests. MDS assessments and activity assessments identified what was very important to these residents, but CAAs did not trigger, care plans lacked instructions for preferred activities, and EMR review showed only a single documented group music activity over a month. A scheduled hand and nail spa activity on the memory unit did not occur as posted; instead, residents were observed resting, sitting, or wandering without the planned activity, while staff reported that there were few activities on the unit and that turning on the TV or passing out snacks was treated as activity. This practice conflicted with the facility’s policy that the Activity Department provide a program supporting residents’ self-esteem, well-being, and satisfaction with an active lifestyle.
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.
Failure to Adjust Activities Program After Resident’s Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to provide an activities program that met the interests and needs of a resident who experienced a significant change in condition and activity participation. The resident, who was cognitively intact with a BIMS score of 15 and served as president of the Resident Council, sustained fractures to the left distal femur and right distal femur/knee area after a fall and was hospitalized. Diagnostic imaging showed an anterior apex angulated, impacted distal femur diametaphyseal fracture on the left and an impacted, comminuted anterior apex angulated fracture of the distal fifth metaphysis of the right knee, with osteopenia noted. After hospitalization, the resident returned to the facility and had an MDS with a significant change assessment, with Section F indicating that it was important for her to do things with groups of people, participate in favorite activities, and attend church services. Record review showed that prior to the fall and fractures, the resident participated in out-of-room activities, including Resident Council, food committee, parties, and socials. The activity care plan, originally created in 2020 and revised multiple times through early 2025, documented numerous preferences and important activities for the resident, such as in-room visits, participation in food committee, church, singing, cooking, gardening, going outside in good weather, pet visits, listening to religious and other music, watching TV, reading, and engaging in religious services and voting. The care plan also noted that it was important for her to engage in her favorite activities and to have opportunities to make choices related to meaningful activities. However, there were no new interventions added or changes made to the activity care plan after her significant change in condition and return from the hospital. Activity participation records from the beginning of the year through the time of survey showed that since her readmission from the hospital, the resident had no out-of-room activity participation and only two documented one-to-one visits, both on the same day. During interview, the resident reported that she could no longer stand, pivot, or get into her wheelchair, and that she was now unable to attend Resident Council meetings, church, or be around people as she had before. She expressed distress about missing family gatherings she had been working toward attending and stated that activity staff did not visit very often and that she could not go out to the groups she liked. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital due to being non–weight bearing, that anything done with her was now in-room, and that social visits were not consistently documented. The Administrator and Director of Recreation acknowledged that documentation showed only two one-to-one visits and no updated interventions on the care plan since before the significant change, leading to the finding that the facility failed to provide a program of activities to meet this resident’s needs and interests after her change in condition.
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 Individualized Activities and Scheduled 1:1 Programming
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to assess residents’ activity preferences and to provide an ongoing activity program consistent with those preferences, as well as a failure to provide scheduled 1:1 activities to certain residents. The facility’s Activities Program policy, dated 6/2020, stated that the facility would provide an activity program designed to meet residents’ needs, interests, and preferences, with assessments completed within seven days of admission and individualized care plans developed and implemented. Observations on multiple days showed Mardi Gras decorations and an outdated February activity calendar posted, but no activities were observed being provided to residents at various times on several dates. The Activity Director reported that her first day was during the survey period, that the March activity calendar had not yet been created, and that she expected activities to be scheduled and calendars distributed and posted. Multiple residents who were cognitively intact and had various diagnoses reported that there were not enough activities and that they were bored. One resident with anxiety, depression, bipolar disorder, schizophrenia, and PTSD stated there were no activities taking place, that the previous Activities Director had left about two weeks earlier, and that the resident paid for a car ride to a store just to get out of the facility. Another resident with stroke, dementia, diabetes, kidney failure, and depression reported doing nothing all day except going to dialysis, expressed interest in puzzles, and recalled that the facility previously had a small bus for outings. Additional residents with diagnoses including diabetes, hearing loss, schizophrenia, multiple sclerosis, insomnia, hypertension, anemia, dementia, and bipolar disorder similarly stated that there were not enough activities, that there were not enough activity staff, and that they were bored most of the time. For several of these residents, record review showed no activity assessments and no care plan documentation related to activity participation or preferences, despite the facility’s policy and the Administrator and DON’s expectation that care plans reflect activity preferences. The survey also found that residents identified by the facility as needing 1:1 activities were not receiving them. A facility 1:1 Activity List showed three residents scheduled for 1:1 activities on specific days of the week, but their medical records contained no documentation of activities offered or provided. These residents had significant cognitive and neurological conditions, including dementia, bipolar disorder, hypertension, malnutrition, Alzheimer’s disease, stroke, hemiplegia, seizure disorder, anxiety disorder, aphasia, mild cognitive impairment, malnutrition, and Rett’s syndrome. Observations of these residents throughout the survey period showed them not engaged in any 1:1 activities. The Activity Director acknowledged that she had not started conducting 1:1 activities for residents on the 1:1 list, and the Administrator and DON stated they expected 1:1 activities to be provided to residents determined to benefit from them.
Failure to Provide and Document Planned 1:1 Activities for a Bed-Bound Resident
Penalty
Summary
Facility staff failed to implement and document individualized 1:1 activity sessions as care planned for a cognitively intact, bed-bound resident with significant physical limitations and multiple medical conditions, including hemiplegia, osteomyelitis, a stage 4 sacral pressure ulcer, generalized muscle weakness, dysphagia, and malnutrition. The resident’s MDS showed dependence on staff for most ADLs, use of a wheelchair for mobility, and little interest or pleasure in activities. The care plan, revised on 03/05/2025, identified the resident as dependent on staff for activities, cognitive stimulation, and social interaction, with a goal for weekly participation in activities of choice. Interventions included inviting the resident to scheduled activities, providing 1:1 bedside or in-room activities if unable to attend group activities, providing an activities calendar and notifying the resident of changes, and having staff converse with the resident during care to encourage engagement. Surveyors’ review of activity task documentation from 02/05/2026 through 03/05/2026 showed only two documented 1:1 activity sessions, despite the care plan’s expectation for weekly participation. Progress notes from 02/02/2026 through 03/06/2026 contained limited entries from the activities department, such as brief social visits and mail delivery, and did not demonstrate consistent or structured 1:1 activity sessions as outlined in the care plan. Observations found the resident in bed or being transported for a medical appointment without signs of distress, and the activities calendar was posted on the wall behind the head of the bed. In an interview, the resident stated she was unaware the activities calendar was in her room, did not know the activities process, and learned of at least one event only when informed by a CNA. The Activities Director and DON both stated that residents with physical limitations who cannot attend group activities should receive weekly 1:1 or bedside activities and be reminded of activities, but the documented record did not show consistent provision or documentation of these 1:1 sessions for this resident.
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