Failure to Provide and Document Individualized Activity Programming
Summary
The facility failed to provide an ongoing activity program to meet the individual interests and needs of residents, as required by its own policy and regulatory standards. The facility’s Activities policy dated April 2025 stated that residents were to receive an ongoing program of group, individual, and independent activities based on comprehensive assessment, care plan, and preferences, designed to support physical, mental, and psychosocial well-being. However, surveyors found that for two residents reviewed for activities, there was no supporting documentation that planned activities were actually provided or that ongoing assessments were completed as required. One resident, identified as R349, had an annual MDS with a BIMS score of 10/15, indicating moderate cognitive impairment. The resident’s care plan, initiated in July 2024 and revised in October 2024, stated that the resident continued to engage in group activities such as bingo and travel/documentary videos, as well as self-directed and 1:1 activities in the room, and interacted daily with others. Despite these care plan statements, review of the EMR progress notes showed no evidence that the activities department conducted 1:1 activities with this resident or that the resident participated in any group activity programs during the assessment period. The Activity Director confirmed there was no documentation of activity participation and that no quarterly activity assessments had been completed for this resident. Another resident, identified as R299, had a history of stroke and epilepsy and a quarterly MDS BIMS score of 4/15, indicating severe cognitive impairment. The activities care plan documented that the resident was dependent on staff for assistance with activities, sensory stimulation, and social interaction, and included specific interventions such as providing opportunities for socialization with peers, individual music listening (gospel and jazz), assistance with TV and telephone use, FaceTime calls with the resident’s mother, and scheduled chaplain visits. The most recent activities assessment described ongoing 1:1 visits for wellness, reminiscence, orientation, inspirational reading, seasonal decorations, music listening, sensory activities, and Geri-chair rides, and noted that scheduled out-of-room group time was not accomplished. However, EMR review from early January through late March 2026 revealed no documentation of participation in any activity program, and repeated observations over several days showed the resident lying in bed without engagement in individual, 1:1, or group activities. The Activity Director confirmed the absence of documentation and that the last activities assessment was not updated quarterly, and the Activity Assistant stated she did not document individual participation, was unaware she was supposed to do so, and did not know the resident’s activity preferences or care plan. The Administrator stated her expectation was that activities be provided and documented per each resident’s needs and interests and that assessments occur on admission, quarterly, and with significant changes in status. This deficient practice had the potential to negatively affect the quality of life for the affected residents.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A facility failed to plan group outings outside the facility for residents who said it was very important to them to go out in a group setting. Five cognitively intact residents on the Resident Council reported there had been no scheduled outings for over a year, and they described feeling sad, unhappy, lonely, or depressed because they could not go to restaurants, shop, socialize, or attend events like movies, bowling, Christmas lights, or parades. The AD and Administrator stated the facility had no van and relied on contract transport for medical appts only.
Failure to provide activity accommodations for a resident with highly impaired hearing. A cognitively intact resident with a fracture preferred watching older TV shows but stated he/she could not hear the television when wanting to watch it. Staff observed the resident in bed with the TV off on multiple occasions, and staff reported that headsets were used for hard-of-hearing residents, but one was not offered to this resident.
Failure to provide planned in-room activities for a resident who preferred not to attend group activities. The resident had intact cognition, anxiety around groups, and documented preferences for reading, news, TV, and one-on-one activities in her room. Records showed she was supposed to receive in-room activities, but no participation documentation was found, and the resident stated she had not received the activities she agreed to. The Activity Director acknowledged the resident had not received in-room activities since admission and said she forgot the resident was on the program.
Activities program did not meet resident needs and interests for multiple residents. One resident wanted more 1:1 conversation but had very limited documented 1:1 activity time, another resident with severe cognitive impairment had minimal documented group participation despite a care plan to encourage involvement, and a third resident said he was not being told about church and group activities even though his MDS and activity preferences showed strong interest in them.
Lack of Meaningful Activities in Memory Care Unit: Two residents in the memory care unit were observed without meaningful engagement, with one resident wandering between areas and another sleeping on a couch in the common area. Staff reported that regular activities were not being provided, the unit did not really use the activity calendar, the TV stayed on the same show for two days, and there was no specific calendar developed to meet the needs of the memory care population.
Failure to Provide Individualized Activity Programming: Two residents with CVA-related paralysis and severe cognitive impairment did not have documented Section F activity preferences or care plans reflecting individualized activities for paralysis. One resident’s assessment showed preferences for fresh air, religious services, and activities throughout the day, but June activity records were inaccurate and the resident was observed in bed watching TV. Staff reported the AD position was vacant after the former AD moved to dietary, and they could not confirm that in-room activities were being provided to bedbound residents.
No Scheduled Outings for Residents Who Wanted Group Activities Outside the Facility
Penalty
Summary
The facility failed to ensure group activities were planned outside of the facility for residents who stated that going out in a group setting was very important to them. Review of the July 2025 through July 2026 activity calendars showed activities inside the facility during the week and on weekends, but no activities scheduled outside of the facility. Observation on 7/13/26 showed the facility was in a rural area within 10 to 15 minutes of local and commercial shops, grocery stores, fast food, and sit-down restaurants. Five residents reviewed for activities—Resident #32, #34, #58, #63, and #66—each had MDS assessments indicating it was very important to have activities that included going outside of the facility and doing things in a group setting, and each was cognitively intact. During the Resident Council meeting on 7/14/26, these residents stated there had been no scheduled group activities outside of the facility since they were admitted or for over a year. They reported that not being able to leave the facility made them feel sad, unhappy, lonely, or depressed, and they described wanting to go to restaurants, shop for personal items, socialize with people outside the facility, go bowling or to the movies, and see Christmas lights or Christmas parades. The Activity Director stated she had worked at the facility for 4 years and had not been able to schedule resident group activities outside of the facility because the facility did not have its own van and contract transportation was used for medical appointments only. She said she had brought the issue to Administration and understood they were trying to work on a transportation solution. The Administrator stated there had been no scheduled activities outside of the facility since he became Administrator over 3 years earlier, and he confirmed the facility did not have its own van and relied on contract transportation for medical appointments.
Failure to Provide TV Accommodations for a Hard-of-Hearing Resident
Penalty
Summary
The facility failed to ensure a resident was provided accommodations for activities for 1 of 1 sampled resident reviewed for activities. Resident 81 was admitted in 6/2026 with a diagnosis of fracture. The 6/29/26 admission MDS indicated the resident was cognitively intact and had highly impaired hearing. The resident was assessed as not using hearing aids, and the 6/29/26 Activity Profile noted a preference for watching older television shows. The resident’s 6/25/26 through 7/7/26 Self Directed Activity form showed the resident watched television on 7/2/26. However, during observations on 7/7/26 at 10:38 AM, 1:42 PM, and 3:37 PM, and on 7/8/26 at 8:13 AM and 11:32 AM, the resident was observed in bed with eyes shut and the television was not on. On 7/6/26 at 2:16 PM, the resident stated he/she could not hear the television when wanting to watch it. Staff stated that hard-of-hearing residents who wanted to listen to television were asked to have a headset brought in by family, that the resident was very hard of hearing and staff had to stand close to the right ear to communicate, and that the activity director did not offer a headset. The DNS stated the facility should have provided headsets for residents who could not hear the television.
Failure to Provide Planned In-Room Activities
Penalty
Summary
The facility failed to provide Resident #5 with an ongoing activity program based on her assessment, care plan, and stated preferences. Resident #5 was admitted with diagnoses including cognitive communication deficit, panic disorder, and age-related cognitive decline. Her admission MDS reflected a BIMS score of 15, indicating intact cognition. Her activity preferences identified books, newspapers, magazines, animals, keeping up with the news, and going outside for fresh air when weather permitted as very important to her. Record review showed Resident #5’s activity assessment stated she preferred not to participate in group activities and received one-on-one in-room activities three times per week. She enjoyed reading, watching television, the news, and coloring. Her comprehensive care plan also reflected that she enjoyed visiting with family and talking on the phone, and listed cooking shows as a preferred television channel. The list of residents on the in-room activity program reflected she was to receive in-room activities, but the in-room activity participation binder did not contain a participation record for her. During interview and observation, Resident #5 was found in bed watching television and stated she did not prefer group activities because she sometimes became nervous around other people. She said she preferred someone to come to her room and do activities with her, and that she had agreed to in-room activities when first admitted. She stated she had not seen that person since admission and did not recall the person’s name, and said she had not received activities in her room. The Activity Director stated Resident #5 was on the in-room activity program but had not received in-room activities since admission and that she had forgotten Resident #5 was to receive them. The Administrator stated residents unable to participate in group activities should receive in-room activities and expected all activities to be documented daily.
Activities Program Did Not Meet Resident Needs and Interests
Penalty
Summary
The facility failed to provide a program of activities to meet the needs and interests of each resident for three residents reviewed. One resident stated he wished someone would come into his room to talk with him and said that visits from Activities had not happened in a long time. His care plan included a goal for 1:1 activities of choice and companionship for conversation, but the Activities Department did not list him among residents receiving one-on-one activities, and his activity participation record showed only one documented 1:1 activity in May and one in June. An Activities Leader acknowledged that she spent time speaking with him while passing meal trays and at other times, but the record did not reflect regular 1:1 activity participation. Another resident’s care plan included an intervention to offer and encourage attendance and involvement in facility activities, and the care plan also stated she was self-directed for activities. Her MDS showed a BIMS score of 1, indicating severe impairment in daily decision-making, and Section F indicated it was somewhat important for her to do things with groups of people and go outside when the weather was good. The activity participation log showed only two group activities in the last three months, with all other activities documented as independent and no refusals of group activities listed. A third resident stated he was not attending church services and group activities because he was not being told about them. His MDS and activity preference interview showed that group activities, Bible study, and religious services were very important to him, but the activity log showed only two group activities and did not document refusals for the religious activities he did not attend.
Lack of Meaningful Activities in Memory Care Unit
Penalty
Summary
The facility failed to provide meaningful activities for residents in the memory care unit, including residents #43 and #44. During observation, resident #43 was seen sitting alone in the dining room, then wandering between his room, the hallway, and the common room, where he sat watching television before wandering back to his room. No activity was occurring at the time. Resident #44 was observed sleeping on the couch in the common area, and staff member G stated that she preferred to sleep on the couch throughout the day and night because she had a fear of sleeping in her room. When questioned, staff member G offered the resident a Dilly Bar and took her outside for fresh air after noting there were no activities occurring. Staff interviews showed that regular activities were not being provided in the memory unit. Staff member G stated the CNAs did not have regular activities and that they just let things happen naturally, despite the facility having a calendar that was not really used in the unit and not having a copy of the calendar available there. Staff member L stated the television had been on the same show for two days straight. Staff member B said there had been discussion about needing more activities, but it had not yet been addressed. NF3 stated resident #43 needed more activities, more time outside, more music, and more ambulation/exercise, and believed the resident was restless and that this contributed to more behaviors. Staff member E stated the memory unit activities included towel folding, tactile boards, church services if wanted, coloring supplies, and occasional nail painting, but there was no specific calendar developed to meet the needs of the memory unit population.
Failure to Provide Individualized Activity Programming
Penalty
Summary
The facility failed to ensure that residents received an ongoing program of activities that supported their interests and psychosocial well-being for two residents, including one resident with a history of cerebral infarction, hemiplegia, hemiparesis, cognitive impairment, weakness and debility, incontinence, and a colostomy, and another resident with CVA, non-Alzheimer's dementia, hemiplegia, hemiparesis, and severe cognitive impairment. Both residents were documented as dependent and not interviewable during observation attempts, and both had care plans that did not mention individualized activities for residents with paralysis. For the first resident, the activity assessment documented preferences such as getting fresh air when weather was good, religious services and practices, and participation in activities in the morning, afternoon, evening, and in the day/activity room. The assessment also noted the resident would need assistance getting to and from activity functions. However, the MDS tab did not show a completed Section F assessment for preferences for customary routine and activities, and the care plan did not include individualized activities for a resident with paralysis. The resident was observed lying in bed watching television, and the activity documentation for June reflected in-room activities that were inaccurately documented. For the second resident, the quarterly MDS reflected a BIMS score of 00 and dependence in functional abilities, but Section F preferences for customary routine and activities were not documented. The care plan also did not mention individualized activities for a resident with paralysis. The resident’s June activity log likewise reflected inaccurate in-room activity documentation. Staff interviews indicated that the former Activity Director had moved to dietary on 06/04/2026, the Activity Director position was vacant, and the former Activity Director had previously taken a sensory cart to bedbound residents, but staff stated that since that transition they had not seen in-room activities occurring for bedbound residents and could not recall the last in-room activities provided to the resident.
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