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F0679
E

Failure to Provide Individualized Activities for Residents with Dementia

Millville, Pennsylvania Survey Completed on 02-14-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide an individualized activities program for residents with dementia and/or sensory deficits, as evidenced by observations, clinical records, and interviews. Five residents were observed in a day room with a television on, but none were engaged with the program or participating in meaningful activities. The facility's activity calendar indicated a scheduled 'Ladies Group' activity, but the female residents in the day room were not participating. Clinical records revealed that these residents had specific activity preferences and cognitive impairments. For example, one resident with bilateral sensorineural hearing loss and cataracts had preferences for music, animals, and religious services, but her activity log showed only one recorded activity in 75 days. Another resident with Alzheimer's disease and cerebrovascular disease had preferences for reading and music, yet his log showed only four activities in the same period. Similar patterns of insufficient engagement were noted for the other residents, indicating a lack of consistent and individualized activities. The Activities Director acknowledged that the department was short-staffed, which hindered their ability to provide one-on-one visits and engagement for residents with dementia and sensory deficits. This staffing issue contributed to the failure to deliver adequate and personalized activities programming, as required by the residents' needs, abilities, and preferences.

Plan Of Correction

0679 An individualized activities program has been developed to meet the specific functional needs, abilities, and preferences for residents 15, 46, 96, 65, and 51 who have dementia and/or sensory deficits. The facility recognizes that other residents with dementia and/or sensory deficits could be affected and will be audited by the Nursing Home Administrator or designee to verify an activities program has been developed to meet their specific needs. The Nursing Home Administrator or designee will re-educate the Activities Director on the need to have an individualized activities program developed to meet the needs of residents who have dementia and/or sensory deficits. The Nursing Home Administrator or designee will randomly audit the activity programs for residents with dementia and/or sensory deficits weekly for 4 weeks and then monthly for 2 months to verify their specific needs are being met. Audits will be submitted to the monthly QA committee meeting for review and any further recommendations for 3 months.

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