Failure to Provide Ongoing Daily Activities Program for All Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide an ongoing, daily program of activities on day and evening shifts as required by its own Activities Program and Facility Assessment Tool. The written Activities Program, dated 11/7/19, requires identification and involvement of each resident in activities designed to appeal to their interests and enhance physical, mental, and psychosocial well-being, including a minimum of four to seven organized activities daily, a mix of group and one-to-one programs, and documentation of attendance and participation. The Facility Assessment Tool, dated 11/1/25, further calls for person-centered psycho/social/spiritual support, culturally competent care, and opportunities for social activities and life enrichment. Despite these written expectations, the January activity calendar contained no scheduled evening or weekend activities. On two consecutive days of observation (1/26/26 and 1/27/26) from 9:15 AM to 3:00 PM, residents were not observed participating in any activities, and no announcements about activities were made. Staff interviews corroborated the lack of programming: an Ombudsman reported that during resident council, residents stated they were very bored, that activities were not being held, no calendar was posted or distributed to rooms, and residents had to find their own things to do. An LPN stated the facility was not providing activities during the day or evening, and that alert residents complained they had to “do their own things” or smoke outside more frequently due to boredom and that they never got to have a movie night. Another LPN working 6:00 AM to 6:00 PM confirmed that no activities were offered that day and that residents were again complaining. Further observations and interviews on 1/28/26 showed systemic issues with activity planning and communication. Multiple residents in the activity room stated that activities were not held every day and that there was no full-time Activity Director, noting that they sometimes only had coloring pages and bingo. A tour with the Interim DON revealed no printed January 2026 activity calendars posted in resident rooms or around the facility. In the activity room, a bulletin board displayed small numbered pieces of paper labeled 1 through 31 with activities listed, but these did not indicate dates or the month and were confirmed by the Interim DON and Housekeeping Supervisor to remain the same each month without being changed. The Housekeeping Supervisor reported she occasionally filled in to perform activities because there was no Activity Director or activity staff, verified that no activities were done on 1/26/26 and 1/27/26, and stated there were no planned activities after 4:00 PM or on weekends.
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