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F0679
E

Failure to Provide and Document Individualized Activity Programs

Colorado Springs, Colorado Survey Completed on 07-24-2025

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 activities designed to support the physical, mental, and psychosocial well-being of three residents, as required by its own policy and federal regulations. For one resident with severe cognitive impairment and a documented interest in dogs and pet therapy, staff did not offer or provide pet therapy during a scheduled session, despite the resident being present in her room and her care plan indicating a strong preference for such activities. Additionally, the television in her room, which could have supported her interests, was not functional and staff were unaware of the location of the remote. Documentation showed that this resident did not attend any emotional activities and only participated in a limited number of intellectual activities over a one-month period, with no evidence of other activity offers or refusals recorded. Another resident, also with severe cognitive impairment and a care plan indicating enjoyment of group activities, pet therapy, and independent leisure materials, was observed not being re-invited to participate in a group ball activity after being distracted and returning to her room. There was no documentation of her participation in social activities or offers of other activities during the review period, despite her care plan specifying regular engagement and individualized interventions. A third resident, who was cognitively intact and expressed a desire to participate in more activities, reported difficulty seeing bingo cards and was not offered pet therapy or other group activities during observed sessions. Documentation for this resident showed no evidence of participation in or offers of emotional, social, physical, or special event activities, and no refusals were recorded. Staff interviews confirmed that activity offers and refusals were inconsistently documented, and that residents were not always invited or encouraged to participate in activities aligned with their preferences and care plans.

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