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:
Failure to Provide Individualized Activities: Two residents with severe cognitive impairment and significant physical limitations had care plans calling for 1:1 in-room activities and support for emotional, intellectual, physical, and social needs, but the record showed only a few documented in-room activity entries over a 12-month period. The Activity Director and other staff could not confirm the frequency of activities provided, and the Administrator stated the documented activity frequency was not sufficient.
Failure to Provide Individualized In-Room Activities: A resident with anxiety, chronic pain, scoliosis, and end stage HF was cognitively intact and had identified music, news, and favorite activities as important, but he reported staying in bed without in-room activities and requested a word search book that he had not received. The AD log for in-room activities could not be found, and facility leadership stated the AD position was open and a qualified candidate was being sought.
Failure to provide ongoing activities for two residents with dementia and severe cognitive impairment. Both residents had documented preferences for music, animals, outdoor time, family visits, and other favorite activities, yet they were repeatedly observed sitting in wheelchairs at the dining table with no activity or stimulation. Staff stated the residents did not participate because of their cognition, while the Activity staff noted there were multiple activities available for residents with cognitive loss.
Failure to Provide Individualized Activity Programming: Three residents with dementia or other significant cognitive impairment had documented activity preferences, but staff did not consistently provide or reapproach activities to match those interests. One resident was observed in-room for long periods without activities being offered, another had limited activity participation despite stated preferences for reading, news, and outdoor time, and a third had no evidence of activity participation and the resident representative reported no invitations to activities. COTA input confirmed the facility lacked an activity director and did not facilitate independent activities for some residents.
Failure to provide ongoing activities for a resident with behavioral needs. A resident who was incapacitated, wandered the halls, and had repeated agitation and resident-to-resident incidents was not given consistent group or individual activities aligned with stated interests such as music and church. The activity log showed many missed activity days, staff said the resident did not attend group activities often, and the facility did not provide individual one-on-one activities.
Failure to provide individualized activities for a resident with severe intellectual disabilities and severe cognitive impairment. The resident’s MDS and care plan documented preferences for music, going outside, and religious activities, and that she was dependent on staff for all ADLs and needed cognitive stimulation and social interaction. However, the EMR lacked documentation of activities offered or participated in, observations showed her sitting without stimulation, and staff stated she had not received the expected 1:1 in-room activities and could not meaningfully participate in group activities.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to provide activities based on the comprehensive assessment and care plan for two residents who were reviewed for activities. Resident #40 had diagnoses including major depressive disorder, muscle wasting and atrophy, Parkinson’s disease, and dementia, and her quarterly MDS reflected a BIMS score of 00 with severe cognitive impairment. Her care plan identified impaired cognitive function/dementia and little or no activity involvement, with interventions for 1:1 in-room activities and encouragement to participate daily. However, record review showed only 9 in-room activity entries documented over the prior 12 months. Resident #56 had diagnoses including fractures, depression, altered mental status, type 2 diabetes, cirrhosis, chronic kidney disease stage 3, and cognitive communication deficit. Her quarterly MDS reflected a BIMS score of 05 with severe cognitive impairment, and her care plan stated she was dependent on staff for meeting emotional, intellectual, physical, and social needs. The care plan included interventions to ensure activities were compatible with her physical and mental capabilities and known interests, to invite her to scheduled activities, and to provide 1:1 bedside or in-room visits and activities if she could not attend out-of-room events. Record review showed only 4 in-room activity entries documented over the prior 12 months. On observation, both residents were lying in bed and were non-interviewable due to severe cognitive impairment. During interviews, the Activity Director stated that non-verbal and non-ambulatory residents unable to join group activities would be provided in-room activities, but she could not explain why only 9 entries were documented for Resident #40 and 4 for Resident #56 and could not locate additional entries. Other staff, including CNA, MA, LVNs, Social Services, the MDS Nurse, the DON, and the Administrator, stated that in-room activities should be provided for residents who do not participate in group activities, but they could not confirm the frequency of activities for either resident. The Administrator also stated that 9 in-room activities in a 12-month period were not sufficient and that she should have known and checked on the activities provided to residents.
Failure to Provide Individualized In-Room Activities
Penalty
Summary
The facility failed to provide an ongoing activities program based on the comprehensive assessment, care plan, and resident preferences for 1 of 17 residents reviewed for activities. Resident #11, a [AGE]-year-old male admitted on [DATE], had diagnoses including anxiety disorder, chronic pain syndrome, scoliosis, and end stage heart failure. His admission MDS dated 06/08/2026 showed a BIMS score of 13, indicating he was cognitively intact, and identified that doing his favorite activity, listening to music, and keeping up with the news were somewhat important to him. His comprehensive care plan dated 07/30/2025 directed the facility to provide a program of activities of interest and to assist him to attend activity functions. During interview, Resident #11 stated he stayed in bed and did not have in-room activities. He said someone had spoken with him about his activity preferences when he first arrived, and he would like a word search book, but he had not told anyone. The Administrator stated he had just hired a part-time person and was looking for the in-room activity logbook from the previous activity director. He later stated he expected the ADs to provide in-room activities and could not find the log of in-room activities. The CHR E stated the AD position was open, the facility was seeking a qualified candidate, and the previous AD had been employed from 3/31/2026 to 5/12/2026.
Failure to Provide Ongoing Activities for Residents With Dementia
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the interests and well-being of two residents with dementia and severe cognitive impairment. R11’s records showed preferences for listening to music, being around animals, spending time outdoors, and participating in favorite activities, and R67’s records showed preferences for listening to music, being around animals, spending time outdoors, visiting with family, going outdoors, and looking out the window. Both residents were dependent on staff for locomotion in wheelchairs, and both had care plans identifying activities they enjoyed or daily routines and activities they should have the opportunity to engage in. During observations on multiple occasions, both residents were seated in their wheelchairs at the dining table with peers while no activity or stimulation was occurring. Staff interviews indicated the residents did not participate in activities because they had dementia or cognitive loss and would sit and people watch. The Activity Staff stated there were multiple activities for residents with cognitive loss to do while seated at the dining room table and that staff education would be needed to ensure activities were brought out and used routinely. The Activity CAA for R67 triggered but lacked an analysis of findings, and the facility policy stated it was the policy to provide an ongoing program to support residents in their choice of activities.
Failure to Provide Individualized Activity Programming
Penalty
Summary
The facility failed to ensure individual activities were provided to meet the interests and support the physical, mental, and psychosocial well-being of 3 residents reviewed for activity participation. Resident #34 had diagnoses including non-Alzheimer's dementia and depression, and the annual MDS showed the resident valued going outside for fresh air, reading books, newspapers, and magazines, being around animals, keeping up with the news, and doing favorite activities. The activity care plan listed interests such as animals, board games, volunteering, dining out, movies, spending time outdoors, listening to the radio, watching sports, and TV, but the resident representative stated staff offered activities and did not reapproach after refusals. Continuous observation showed resident #34 remained in the room in a recliner for extended periods on 7/29/26 without activities being offered, despite scheduled activities that day including daily chronicle, fun with fitness, reading time, treats, music, and reading/trivia. The activity participation record showed the resident was offered activities 115 times from 4/28/26 through 7/29/26, mostly independent activities, with 52 refusals documented. COTA #1 stated the facility did not have an activity director, she did not perform activities daily, and the facility did not facilitate independent activities for resident #34 or resident #123. Resident #123 had a BIMS score of 8/15, indicating moderate cognitive impairment, and diagnoses including progressive neurological conditions, non-Alzheimer's dementia, and seizure disorder or epilepsy. The resident stated it was very important to read books, newspapers, and magazines, keep up with the news, and go outside for fresh air, and the care plan listed preferred activities such as arts and crafts, ceramics, visiting with others, shuffleboard, sports, TV, movies, listening to oldies, and being outdoors. The activity participation record showed 75 activity offers with 10 refusals. Resident #178 had a BIMS score of 3/15, severe cognitive impairment, and diagnoses including nontraumatic intracerebral hemorrhage and macular degeneration; the resident preferred animals, music, favorite activities, and going outdoors, but observations and the resident representative indicated the resident did not participate in group or individual activities, had not been invited to activities, and had no activity calendar in the room. The record showed no evidence of activity participation.
Failure to Provide Ongoing Activities for a Resident With Behavioral Needs
Penalty
Summary
The facility failed to ensure Resident #42 was provided an ongoing program of group and individual activities designed to meet the resident’s interests and support physical, mental, and psychosocial well-being. The resident was incapacitated, had no BIMS completed because the resident hardly/never understood, and was documented as being self-directed, wandering throughout the facility, and preferring music and church. The activities policy required resident-centered care and individual activities, but the activities leader reported the facility did not provide individual one-on-one activities for residents and that the resident did not go to group activities often. The resident’s record showed repeated behavioral concerns, including agitation, combativeness, exit-seeking, entering other residents’ rooms, verbal abuse, and resident-to-resident altercations. Clinical Psychological Services recommended consistent redirection, frequent re-orientation, a structured environment, and limited overstimulation. The care plan documented physical aggression episodes toward other residents, but additional behavioral episodes were not updated on the care plan, and social services confirmed there were no resident-to-resident interventions on the plan of care. The Activity Participation Log showed numerous dates when activities were not provided across February through July 2026. Surveyor observation also found the resident wandering in hallways and being redirected by staff. Staff interviews confirmed the resident’s behavioral interventions were inconsistent, the resident liked to walk the halls, and the facility relied on packets of images for self-directed activity rather than providing individual one-on-one activities.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to develop an individualized activity plan for a resident with severe intellectual disabilities and severe cognitive impairment. The resident’s EMR documented a diagnosis of severe intellectual disabilities, and the Annual MDS documented that staff interviewed the resident and recorded that it was very important for her to listen to music she liked, go outside when the weather was nice, and somewhat important for her to participate in religious activities. The MDS also documented that she was dependent on staff for all ADLs. Her Activity CAA was not triggered, and her Quarterly MDS again documented severe cognitive impairment and dependence on staff for all ADLs. Her Care Plan documented that she was dependent on staff for activities, cognitive stimulation, and social interaction due to her cognitive deficits. The resident’s Recreation Assessment documented that she preferred to participate in activities once weekly in her room, but her EMR from 06/28/26 through 07/26/2026 lacked documentation of any activities offered or participated in. On observation, she sat in her wheelchair in the TV commons area with no visual or audible stimulation provided, and at another time she sat with her back toward the turned-on TV. CNA M stated she had not seen anyone do activities with the resident in her room and that she would go to Bingo at times but was unable to participate and usually fell asleep. Activity Staff Z stated she had not done any in-room activities with the resident and that the resident should have had 1:1 activities due to her cognitive impairment, but those had not taken place. LN H stated the resident had not received any 1:1 activity in her room, and Administrative Staff A stated the expectation was for dependent residents to have 1:1 activity when they were unable to participate in other activities.
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