Failure to Assist Residents with Participation in Activities
Summary
Facility staff failed to implement the policy on quality of life by not assisting three out of four sampled residents to participate in activities. These residents had significant cognitive impairments and were dependent on staff for daily care, including oral hygiene, toileting, and personal hygiene. Medical records indicated that each resident was permitted to participate in activities as long as it did not conflict with their treatment plan. Despite this, repeated observations throughout the day showed that these residents remained in bed and were not offered the opportunity to get out of bed or attend activities. Interviews with staff revealed that certified nursing assistants (CNAs) did not routinely offer or assist these residents to get out of bed or participate in activities. Reasons given included lack of instruction from licensed nursing staff, time constraints, and assumptions about the residents' ability to participate due to medical devices or communication barriers. For example, one CNA stated that a resident with a gastrostomy tube was not brought to activities because of the tube, and another CNA indicated that a nonverbal resident was not offered the opportunity to get out of bed because of her communication limitations. Further interviews with the registered nurse, activities director, director of staff development, director of nursing, and administrator confirmed that the facility's policy required staff to assist residents in getting out of bed and participating in activities to promote quality of life. These staff members acknowledged that the policy was not being followed and that residents were not being provided with opportunities for stimulation and social interaction as required.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to properly position residents during meals, affecting three individuals on the secured unit. Observations showed residents in tilt wheelchairs at inappropriate angles and one resident in a low wheelchair without leg rests, unable to reach their meal. Staff did not intervene to reposition the residents, and interviews confirmed the improper positioning. The facility's policy on dignity and respect was not followed.
Improper Positioning of Residents During Meals
Penalty
Summary
The facility failed to ensure proper positioning of residents during meals on the secured unit, affecting three residents. Observations revealed that two residents were seated in specialty tilt wheelchairs at angles between 60 to 75 degrees, with one resident's table height reaching their chin throughout the meal. The staff did not intervene or reposition the residents during the meal observation. Another resident was observed sitting in a low wheelchair without leg rests, with their feet dangling, and was not positioned properly at the table during breakfast. Despite staff presence, no intervention was made to reposition the resident to allow proper access to their meal. Interviews with staff confirmed the improper positioning of residents during meals. One staff member acknowledged that a resident was not positioned correctly at the table, citing concerns about the resident grabbing items off the table. The Director of Nursing verified that residents should be upright and properly positioned at an appropriate table height during meals. The facility's policy on Quality of Life - Dignity emphasizes care that promotes dignity, respect, and individuality, which was not adhered to in these instances.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
