Failure to Provide and Document Resident Activities
Penalty
Summary
The facility failed to provide an ongoing activity program to support residents' choices and needs for both group and individual activities, as well as independent activities, for the entire months of August and September 2025. Record review showed there were no activity participation records for these two months, and the Activity Director confirmed that there was no documentation of any activities provided during this period. The absence of activities was also corroborated by resident interviews, with multiple residents reporting a lack of activities and expressing feelings of boredom during this time. Three residents were specifically reviewed in relation to this deficiency. One resident, with diagnoses including major depressive disorder and other depressive disorders, reported feeling bored and stated that there were approximately two or three months with very few activities, except for reading and watching TV. Another resident, with mild intellectual abilities and major depressive disorder, stated that there were months with no activities except for occasional church services, though he did not get bored due to personal activities and family support. A third resident, diagnosed with bipolar disorder and generalized anxiety disorder, also reported periods without visible activities and occasional boredom, though he preferred solitary activities and sometimes attended music events or parties. The Activity Director, who had been certified and in her role for over ten years, admitted to not providing or documenting activities during the deficient months and did not request assistance. The Administrator was unaware of the lack of documentation until October 2025, as she had not yet monitored the activity department. The facility's job description for the Activity Director included maintaining detailed records of activity programs and participation, which was not fulfilled during the months in question.