F0679

E

Failure to Provide Resident-Centered, Dementia-Appropriate Activities

Belvidere, Illinois Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide a resident-centered, meaningful activity program for multiple residents with dementia. One resident with late-onset Alzheimer’s disease was repeatedly placed in the dining room for extended periods, seated at a table with many other residents while a 1990s Western drama played on the television that she did not like and did not watch. Activity staff were seated in a corner with only one resident coloring, and most residents were asleep. This resident was observed propelling herself in her wheelchair, asking how long she had to sit there, stating she wanted to return to her room to watch TV, and describing the situation as “torture” and that residents were left with “no water.” Staff initially refused to let her return to her room due to fall risk, left her without engagement, and later only provided coloring materials at a table in the corner. Her care plan did not address her activity interests or abilities.

Another resident with unspecified dementia sat in the dining room in a wheelchair holding a baby doll, kissing and cradling it, until another resident took the doll away without staff noticing or intervening. This resident then sat without any activity, commented to another resident that they were just “set out here,” and placed a small activity blanket on the floor, stating someone else would pick it up. An activity aide later removed the stuffed animal, pillow, and blanket from the area and put them away, and the resident was turned to face the table as preparations for lunch began. No structured or individualized activities were provided during this time, despite the resident’s care plan noting that she likes to sit and talk with others, go outside, loves dogs, and enjoys card games such as poker and rummy.

Two additional residents with dementia were also not provided with meaningful, individualized activities. One resident repeatedly walked between her room and the dining room, briefly sitting and then leaving, and when she asked for help finding food, staff confirmed she had already eaten and only offered cookies before seating her in front of the same television program that had been playing all day; no staff attempted to engage her in activities consistent with her care plan, which documented interests in arts and crafts, music, bowling, and Catholic faith, and noted that she primarily speaks Spanish. Another resident with dementia spent the morning hours seated in a wheelchair in the dining room with her back to the television, mostly asleep, with no staff engagement and no access to the TV she could not see, despite a care plan stating she would attend meaningful activities such as watching TV, listening to music, going outside, walking the unit, and visiting other residents. The activity director later stated that due to an influenza outbreak there were to be no communal activities, that staff were instructed to focus on one-on-one activities, and that the posted activity calendar listed multiple group activities that were not observed occurring on the days of the survey.