Failure to Provide Ongoing, Scheduled Activities Program Based on Resident Preferences
Penalty
Summary
The deficiency involves the facility’s failure to provide an ongoing activities program that followed the posted calendar and met residents’ assessed interests and care plan goals. The February activity calendar showed no activities scheduled on weekends, and surveyor observations on a Sunday afternoon found no activities occurring. On subsequent weekdays, activities listed on the calendar, such as bingo and other group events, were not provided as scheduled, with no alternative or backup activities implemented when the Activity Director was absent. Two residents with moderate cognitive impairment and depression, both care planned to benefit from and be encouraged to attend group and individual activities, reported that scheduled activities were not occurring. One resident, with diagnoses including dementia, major depressive disorder, and mobility limitations, had an MDS indicating that doing favorite activities and participating in groups were very important, and her care plan called for out-of-room social, spiritual, and stimulating activities at least twice weekly. She stated there was no bingo on a day it was scheduled and that there were no weekend activities, noting the Activity Director had not worked for several days. Another resident, with Alzheimer’s disease, dementia, major depressive disorder, and mobility issues, had an MDS indicating that keeping up with the news, doing things with groups, doing favorite activities, and going outside were very important, and his care plan directed encouragement to participate in exercise and activity programs. He reported that “pretty nails” and “appetizer hour” did not occur as scheduled and that there had been no activities all week or on weekends. Interviews with the ADM and the Activity Director confirmed that the Activity Director had been physically unable to work during the survey week and did not work weekends, and that there was no assistant or formal backup plan to ensure activities occurred when she was absent. The ADM stated he would get staff together to ensure residents received scheduled activities if the Activity Director could not work, but observations showed that scheduled activities such as bingo were not consistently provided. The Activity Director stated she was unaware that activities were not being held, that one-to-one activity notes were not kept at the facility, and that she did not have a backup plan for her absence, despite facility policy requiring an ongoing activity program based on residents’ interests and needs, including programming throughout the entire week and for residents unable to participate in groups. Resident Council minutes from several months documented that residents’ favorite activity was bingo and that they wanted more bingo, including twice weekly, yet bingo and other posted activities were not reliably provided as scheduled.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.