Failure to Conduct Activity Assessments and Provide Activities
Summary
The facility failed to carry out activities according to a resident's care plan and did not conduct ongoing activity assessments for residents. Specifically, Resident #25 was observed multiple times without the daily newspaper in their preferred language, which was part of their care plan. The Activities Director (AD) was unaware of who was responsible for providing the newspaper and admitted to a lack of documentation regarding Resident #25's participation in activities. The AD also mentioned that activity assessments should be conducted quarterly, but there was no evidence of this being done. Additionally, the facility did not have updated activity assessments or participation documentation for several residents, including Residents #3, #21, #25, #83, and #84. For instance, Resident #3's last documented activity assessment was from 2022, and there were no participation logs available. Resident #21 had no activity assessments or documentation, and Resident #83's assessment was incomplete and not entered into the electronic medical record (EMR). Resident #84 also lacked activity assessments and participation documentation. The facility was unable to provide any documentation confirming residents' participation in activities. The surveyor requested the facility's policy on activities but only received a job description for the Recreation Director, which outlined responsibilities such as coordinating and documenting assessments and designing a comprehensive activity program. The facility administration had no additional information to offer when these concerns were discussed.
Plan Of Correction
1: The facility implemented a recreation attendance record for the 7 residents identified. All care plans for the 7 residents identified were updated appropriately. 2: All residents had the potential to be affected by the deficient practice so the facility implemented a recreation attendance record for all other residents as well. 3: The care plans for all current residents were reviewed and updated as needed. The Activities director and staff were educated on proper care planning of activity preferences as well as the recreation attendance record policy/process. 4: The Administrator/designee will audit 5 care plans weekly x4 to ensure they reflect activity preferences that were identified in the assessment. The administrator/designee will also audit 10 resident attendance records weekly x4 then monthly x2 ensuring proper compliance. Results will be reported to the QAPI committee for review and action as necessary. 5: 3-3-2025 Element One Corrective Actions: A Certified Activities Director reviewed, revised as appropriate, and signed the activity participation review (APR) for Resident #1. The care plan was also reviewed and updated as needed to reflect the current interests, abilities, and preferences. A Certified Activities Director reviewed, revised as appropriate, and signed the activity participation review (APR) for Resident #6. The care plan was also reviewed and updated as needed to reflect the current interests, abilities, and preferences of Resident #6 and activity staff were re-educated about the changes. A Certified Activities Director reviewed, revised as appropriate, and signed the activity participation review (APR) for Resident #7. The care plan was also reviewed and updated as needed to reflect the current interests, abilities, and preferences of Resident #7 and activity staff were re-educated about the changes. The facility implemented a recreation attendance record to be completed each day to reflect attendance at group activities. In-room visits are documented on the same form noting date and Resident. Element Two Identification of At-Risk Residents: All residents had the potential to be affected by the practice. Element Three Systemic Change: An audit of the most recent APR for current Residents was completed by Certified Activity Directors and changes made as appropriate to reflect the current interests, abilities, and preferences of each Resident. The care plan of each Resident was reviewed and updated as appropriate based on the APR and activity staff educated about any changes. Activities staff were re-educated about the recreation attendance record to be completed daily that reflects attendance at group programs and in-room visits. A Certified Activity Director (CAD) was hired and started on March 3, 2025. The new CAD is being mentored by sister facility CADs as needed. Element Four - QAPI: The Activity Director/designee will audit resident group attendance and in-room visit records weekly x4 then monthly x2 ensuring proper compliance. Results will be reported to the QAPI committee for review and action as necessary. Completion Date: 3-5-2025
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A facility failed to provide an ongoing activity program that met residents’ interests and failed to inform residents of available activities. Two cognitively intact residents said group activities and favorite activities were important, but one resident had no documented activity participation during the review period and both residents reported no posted activity calendar, limited or no staff notification, and activities occurring mainly on another floor. Staff confirmed there was no Activities Director, activities were not routinely occurring on the third floor, and the calendar was not posted for resident viewing.
Failure to Provide Ongoing Individual and Independent Activities: Two residents with significant medical and functional limitations did not have consistent documentation of individual or independent activities that matched their preferences and psychosocial needs. One resident with CAD, ESRD, DM, CVA, depression, pain, and bedfast status reported wanting in-room activities but said staff were too busy to offer them, while another resident with severe cognitive impairment, hemiplegia, anxiety, and wheelchair dependence preferred family visits, TV, snacks, and music and had limited activity documentation despite care plan directions and psych recommendations for social and cognitively stimulating engagement.
Failure to Provide Activities for a Resident with Dementia: A resident with dementia, anxiety, severe cognitive impairment, and total ADL dependence was not provided an activities program to support social needs and psychosocial well-being. Records showed only one 1:1 activity over several months, while observations found the resident repeatedly in bed with the TV on. Nurses acknowledged turnover in the activities dept and that there had been no activities in the memory unit for several days, despite care plan directions to invite and encourage participation and provide in-room activities.
Failure to Provide Individualized Activity Programs: Three residents with severe cognitive impairment and other significant conditions did not receive activity programs matched to their preferences and needs. One resident with dementia and another with Alzheimer’s disease were repeatedly observed sitting alone or in bed without music, meaningful engagement, or documented 1:1 activities after moving to the rehab hallway, while staff said activity support did not come to that unit. A blind resident with severe cognitive impairment also had no documented music or outdoor activities despite stated preferences, and the AD noted staff had been too busy to provide those activities.
Failure to Provide Documented Activity Programming: Three residents with depression, dementia, anxiety, bipolar disorder, and severe cognitive impairment had care plans and stated preferences for meaningful activities, including in-room and group options, but activity records showed no documented participation in either in-room or group activities during the reviewed periods. The Activity Director acknowledged one resident was not on the in-room list, another should have been receiving in-room activities, and a third had been forgotten for required 1:1 activities.
Inconsistent Activity Program and Frequent Cancellations: The facility failed to provide an ongoing activity program with daily organized options for 3 residents, including a resident with bipolar disorder, a resident with hemiplegia/hemiparesis after CVA, and a resident with Alzheimer's disease. The calendar showed self-directed activities every weekend, while residents and a CNA reported that scheduled events such as the coffee social were often cancelled or not actually held, leaving little more than TV or independent packets for engagement. The AD said 2 to 3 activities were cancelled each week and that weekend activities were self-directed due to a conflict, while the Admin acknowledged the weekend schedule did not meet facility standards and noted prior complaints about lack of activities.
Lack of Posted Activity Schedule and Resident Notification
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet residents’ interests and well-being and failed to ensure residents were informed of available activities for two residents who identified group activities and favorite activities as important. R3 was cognitively intact with a BIMS score of 15 and, on the activity preference assessment, identified doing things with groups of people and participating in favorite activities as somewhat important. R37 was cognitively intact and dependent on a mechanical device and assist of 2 for transfers; he indicated it was very important to attend activities. R3’s care plan directed staff to provide an activities calendar and notify her of changes, but record review showed no documented activity participation for R3 between 5/1/26 and 5/16/26, and no sign-in sheets were available for 5/17/26 through 5/31/26. Observation showed no activities calendar posted in any public area on the third floor or in the elevator. R3 stated she and another resident had tried to organize activities themselves because no formal activities were occurring, that she never saw the activities aide on the third floor, and that activities, if held, occurred on the second floor without notifying third-floor residents. She stated, “We are all bored up here on third floor.” R37’s care plan directed staff to encourage participation in activities that promote exercise and improved mobility. He stated there were no activities available, that he would have liked to participate if offered, and that he had informed staff of a desire to attend an auction activity but no staff assisted him to attend. He also stated staff did not invite him to activities and there was no communication about what activities were available or when they occurred. Staff interviews confirmed the facility had no Activities Director, activities were mainly occurring on the second floor, there was no activities calendar posted on the third floor, and activities had not been routinely occurring, especially on the third floor.
Failure to Provide Ongoing Individual and Independent Activities
Penalty
Summary
The facility failed to ensure that residents received an ongoing program of activities that supported their choices and met their physical, mental, and psychosocial needs for 2 of 8 residents reviewed. The deficiency involved Resident #26 and Resident #34, both of whom had care plans that called for participation in activities of choice and invitations to group activities, but the record did not show consistent individual or independent activities being provided and documented during the review period. Resident #26 was a female with diagnoses including CAD, HTN, ESRD, DM, CVA, and depression. Her MDS showed a BIMS score of 13, indicating cognition intact, and she required dependent to setup or clean-up assistance and used a manual wheelchair. Her care plan included attending activities of choice, maintaining involvement in cognitive stimulation and social activities, and receiving assistance/escort to activities, but no additional comments were provided and independent bedbound room activities were not noted as an intervention. An activity progress note stated she participated in activities of choice weekly and that she preferred in-room activities such as her cell phone, social media, family phone calls, games, texting, and reading. A pressure ulcer risk evaluation identified her as bedfast and very limited, and a social service assessment noted she had been in bed more, preferred to stay in bed, and was on psych services for depression, anxiety, and mood disorder. During observation and interview, she was lying in bed watching TV and stated that pain in her lower extremities made it difficult to walk, that she could not participate in group activities, and that she did not believe staff provided in-room activities because they were constantly busy and in a hurry. Resident #34 was a male with diagnoses including HTN, PVD, renal insufficiency, neurogenic bladder, DM, CVA, hemiplegia, and anxiety disorder. His MDS showed a BIMS score of 07, indicating severe cognitive impairment, and he required dependent to substantial/maximal assistance and used a manual wheelchair. His care plan directed staff to encourage participation in activities and invite him to group activities. An activity progress note documented that he declined out-of-room programs and preferred family visits, TV, snacks, and music. Psychiatric services recommended exercise, social functions, and cognitively stimulating activities such as reading the newspaper and audiobooks. During observation, he was lying in bed, and an interview attempt showed difficulty with speech and inability to be understood. The Activity Director stated bedbound residents were provided in-room activities 3 times per week and that individual activities were documented in the EMR or daily activity roster, but she was unsure why Resident #26 had only one activity progress note over a 12-week period and why Resident #34 had only two activity progress notes over a 16-week period. She also stated she could not find the documentation in the hard copy roster and activity progress notes.
Failure to Provide Activities for a Resident with Dementia
Penalty
Summary
The facility failed to implement an activities program to support a resident’s social needs with involvement in both individual and group activities to support his highest psychosocial well-being when staff failed to offer and provide activities of his choice. The resident had diagnoses of dementia, anxiety, cognitive communication deficit, and senile degeneration of the brain. His quarterly MDS dated 05/15/26 documented a BIMS score of zero, indicating severely impaired cognition, and noted he was rarely or never understood and dependent on staff for all ADLs. His care plan directed staff to invite him to all scheduled activities, encourage participation, provide in-room activities as desired, and offer orientation to the facility’s daily schedule. Review of the resident’s EMR from 03/01/26 through 06/01/26 showed only one documented activity, a 1:1 visit on 05/04/26. Observations on 06/01/26 and 06/02/26 showed the resident repeatedly lying in bed with the TV on, with no documented participation in activities. On 06/03/26, an Administrative Nurse stated the resident liked to watch TV and listen to music and acknowledged there had been a lot of turnover in the activities department, that residents liked to watch TV when activities occurred, and that she was aware there had not been activities in memory care in the last few days. Another Administrative Nurse stated the facility was lacking in activities and was aware there were no activities in the memory unit. The facility’s Dementia Care policy stated residents with dementia were to receive appropriate treatment and services to meet their highest practicable physical, mental, and psychosocial well-being.
Failure to Provide Individualized Activity Programs
Penalty
Summary
The facility failed to provide an ongoing activity program that met the individual interests and needs of three cognitively impaired residents. Resident #32 had diagnoses including dementia with psychotic behavior and Alzheimer's disease, was severely cognitively impaired, and was dependent on staff for all ADLs. Her MDS showed preferences for listening to music, keeping up with news, participating in group activities, and spending time outdoors. Although her care plan called for activities compatible with her abilities and interests, 1:1 bedside or in-room activities when she could not attend group events, and staff assistance and escort to activities, the record contained no activity notes after 3/9/26 through 5/28/26 showing participation in activities of interest. After Resident #32 transferred from the LEU to the 500 hallway, observations showed her sitting alone in a wheelchair in the dining room and near the nursing station, staring ahead or at a towel, with no music, television, or staff interaction. She was also observed lying in bed talking to herself while a television played at low volume on the opposite side of the room, out of her view. Nurse Aide #1 stated activity staff did not come to the rehab unit, the resident could not attend activities without assistance, and there was no music system or television available in the dining room. The Activity Director stated the resident enjoyed preaching, pastor services, color sorting, and matching games, acknowledged that no 1:1 activities were completed and no music or television was available in the dining room, and said the resident would not be triggered for 1:1 activities until the care plan was updated. Resident #44 had diagnoses including Alzheimer's disease, dementia, and major depressive disorder, was severely cognitively impaired, and was dependent on staff for all ADLs. Her MDS identified preferences for listening to music, being around pets, attending religious services, participating in group activities, and going outdoors in good weather. Her care plan required staff support for emotional, intellectual, and social needs, including inviting her to activities, matching activities to her interests and abilities, and providing assistance or escort. After she moved from the LEU to the 500 hallway, there were no activity notes or documentation, and observations showed her sitting alone in the dining room or near the nursing station with no television, music, or staff interaction, and later lying in bed while the television played at low volume and she appeared disinterested. Nurse Aide #1 stated activity staff never came to the rehab unit, there was no music or television available in the dining room, and she could not take the resident to group activities because she needed to provide care to other residents. The Activity Director stated the resident preferred music, acknowledged she had not received activities since moving to the 500 hallway, and said 1:1 visits occurred about once per month. Resident #9 had legal blindness and adjustment disorder with mixed anxiety and depressed mood, and his MDS showed severe cognitive impairment. His activity preferences included listening to music and going outside, but his care plan contained no goals or interventions related to activities. May 2026 documentation showed only self-directed activities such as watching TV and relaxing in his room, along with 1:1 notes for hydration and snacks, with no documentation that he listened to music or went outside. Observations found him lying in bed facing the wall with no music playing, no TV on, and no independent activities available in his room. Nurse Aide #2 stated he was blind, did not like group activities, and she had not seen activity staff provide music or outdoor activities. The Activity Director stated she knew his preferences included music and going outdoors, but due to a busy staff schedule, staff had not been able to provide those preferred activities.
Failure to Provide Documented Activity Programming
Penalty
Summary
The facility failed to provide an ongoing activity program that supported residents’ choices for facility-sponsored group activities, individual activities, and independent activities for three residents reviewed. The deficiency involved Residents #1, #2, and #3, all of whom had documented activity preferences and care plan interventions for in-room or preference-based activities, but the activity participation records showed no in-room activities and no group activity participation during the cited review periods. Resident #1 was a male with diagnoses including major depressive disorder, anxiety disorder, and alcohol abuse with alcohol-induced mood disorder. His records showed intact cognition on admission, later moderate impairment on a quarterly MDS, and he felt depressed and hopeless. His activity preferences included reading, music, animals, news, favorite activities, going outside, and religious services. His care plan identified a need for in-room activities and reminders to attend preferred activities, and an activity progress note stated he needed reminders for bingo, outside social, party games, cooking class, and other activities. However, the activity participation records showed no in-room activities or group activities during the reviewed months. Resident #2 was a male with Alzheimer’s disease with early onset, bipolar disorder, major depressive disorder, and anxiety disorder. His annual MDS showed severely impaired cognition, and his preferences included reading, music, animals, news, group activities, favorite activities, going outside, and religious services. His care plan directed staff to provide in-room activities as needed and to remind and assist him to attend preferred activities. The activity participation record showed no in-room activities or group activities during the reviewed periods. During interview, the Activity Director stated she did not realize he had in-room activities on his care plan and acknowledged he should have been receiving them. Resident #3 was a male with dementia with behavioral disturbance, depression, and lack of coordination. His MDS assessments showed severely impaired cognition, and he had physical and verbal behaviors. His preferences included music, animals, news, group activities, favorite activities, outdoor time, and religious activities. His care plan stated he needed meaningful activities appropriate to his cognitive and physical abilities, a consistent daily routine, and in-room activities, including posting a monthly calendar in his room. The activity participation records showed no in-room activities or group activities during April 2026, and the Activity Department list of residents needing in-room activities did not include him. The Activity Director stated she forgot he was required to receive in-room activities and said he would do better with them.
Inconsistent Activity Program and Frequent Cancellations
Penalty
Summary
The facility failed to ensure residents received an ongoing program of activities that supported their choices and psychosocial well-being, including facility-sponsored group activities, individual activities, and independent activities. The deficiency involved 3 of 3 residents reviewed for activities: a female resident with bipolar disorder and intact cognition, a male resident with hemiplegia and hemiparesis following cerebral infarction and intact cognition, and a female resident with Alzheimer's disease and moderately impaired cognition. The facility’s May 2026 activities calendar listed self-directed activities on every Saturday and Sunday, totaling 10 days, rather than organized daily activities. Resident interviews and staff statements showed that scheduled activities were frequently cancelled or not actually held. One resident said the coffee social and most weekday activities were often not hosted by the facility, and that the weekend self-directed activities meant there was nothing scheduled except television, which had been occurring for several months and made her feel terrible. Another resident said he was satisfied overall but wished there were weekend activities. A CNA stated there was no coffee social or other organized activity occurring at the time of interview, that the calendar did not reflect which activities were actually hosted, and that residents frequently reported boredom due to lack of activities. The AD stated she was unsure whether the coffee social occurred because she had arrived late and had not arranged for anyone else to host it. She also stated that approximately 2 to 3 scheduled activities were cancelled each week and that weekend activities were scheduled as self-directed because of a conflict with a resident regarding weekend activity type. She said she prepared activity packets for interested residents and used an activity cart with snacks and independent activities as backup. The Admin stated she was aware that every weekend in May 2026 was scheduled as self-directed, that this did not meet facility standards, and that the AD had been on a performance improvement plan since January 2026 due to complaints from residents and staff about lack of activities, poor communication, and inconsistent efforts to engage residents in activities.
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