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F0679
E

Failure to Provide and Document Resident Activities

Ashland, Virginia Survey Completed on 08-21-2025

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

Facility staff failed to provide activities to meet the needs and preferences of five residents over a period of several months. For one resident with no cognitive impairment, there was no evidence of activities being provided according to their stated preferences, which included listening to music, keeping up with the news, group activities, favorite pastimes, and going outside for fresh air. The facility lacked documentation of activities for this resident and others between February and June, and the executive director confirmed that there was no activities director during much of this time, resulting in gaps in activity provision and documentation. Several other residents, including those with severe cognitive impairment and dementia, also did not receive documented activities during the same period. These residents had care plans and MDS assessments indicating the importance of activities such as music, religious services, group events, going outside, and reading materials. Staff interviews revealed that, due to staffing challenges and the absence of an activities director, activities were not consistently offered, especially in the memory care unit. Some CNAs attempted to provide informal activities, but these were not regular or documented, and there was no structured program in place until a new activities director was hired at the end of June. The facility's own policy required group activities to be scheduled and documented to enhance residents' well-being and self-esteem, with participation recorded in the electronic health record and summaries provided at least quarterly. However, administrative and clinical staff acknowledged the lack of evidence for activity participation during the cited period. The deficiency was identified through resident and staff interviews, review of facility documents, and clinical records, all of which confirmed the absence of required activities and documentation for multiple residents.

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