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F0679
E

Failure to Provide Individualized and Ongoing Activity Program

Waukesha, Wisconsin Survey Completed on 06-09-2025

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 an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident, as evidenced by observations, interviews, and record reviews for four residents. One resident with severe cognitive impairment and multiple diagnoses, including dementia and depression, was observed sitting for extended periods without any activities, conversation, or stimulation, despite documentation indicating limited participation in group activities such as bingo and movies. Staff discussions revealed uncertainty about the resident's preferences and inconsistent efforts to engage the resident in meaningful activities. Another resident, who was cognitively intact and had chronic medical conditions, expressed dissatisfaction with the variety of activities available, stating there was nothing to do. The resident's care plan listed only a few leisure pursuits and lacked measurable goals or evidence of personalization. Activity participation records showed sporadic involvement in activities, and the Activity Director acknowledged that care plans may not clearly communicate residents' preferences or goals to new staff. Two additional residents with severe cognitive impairment and significant physical limitations had care plans that either lacked an activities component or did not specify preferred activities. Documentation showed minimal participation in activities, with little detail on the nature or enjoyment of the activities. Interviews with the Activity Director indicated a lack of awareness of some residents' preferences and an absence of individualized activity planning in the care plans. These deficiencies demonstrate the facility's failure to implement its own policy requiring activities to be tailored to each resident's interests, abilities, and preferences.

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