Failure to Provide Ongoing, Individualized Activity Program for Residents
Summary
The deficiency involves the facility’s failure to provide an ongoing, comprehensive activity program that met residents’ individual preferences and needs, as required by facility policy. Surveyors found that activity assessments and care plans identified specific interests and the importance of various activities for residents, but the facility did not implement or document activities consistent with those plans. Activity calendars lacked scheduled one-on-one activities for certain months, and there was little variety in daily activities from week to week. The facility’s own policy required admission activity assessments, ongoing updates, and individualized activity plans, including one-on-one activities to be completed per the activity calendar, but these were not carried out as written. One resident, identified as Resident #28, had multiple medical diagnoses including encephalopathy, heart failure, anemia, diabetes, and a fractured hip, and was cognitively intact per the MDS. The activity assessment for this resident documented numerous current interests and their importance, including one-on-one activities with animals/pets, beauty/barber services, exercise, family/friend visits, gardening, movies/TV, cooking, and current events, as well as small group interests such as bingo, cards, resident council, volunteering, walking, arts/crafts, community outings, and social parties. The care plan stated the resident was involved with activities little of the time and included interventions such as assisting the resident to activities, encouraging participation, inviting to resident council, breaking activities into manageable tasks, and providing an activity calendar. However, review of the medical record showed no evidence that the resident was offered or participated in the identified one-on-one or group activities during the review period. For Resident #28, the activity calendars for a specific month showed scheduled one-on-one visits on several dates and listed group activities such as weekly bingo, multiple weekly card/game sessions, weekly pet therapy, weekly outings, and a monthly spa day. Yet, the record of one-on-one activities contained only a few brief contacts, such as staff visiting while the resident’s husband was present, offering popsicles or snacks, and one instance of offering a word search that was declined by the husband when the resident was sleeping. The Activity Supervisor confirmed that these few documented contacts were all that had been provided since the resident’s admission. There was no documentation that the resident’s stated preferences for activities like bingo, pool, happy hour music, or other listed interests were implemented. Another resident, identified as Resident #2, had extensive medical conditions including CVA with hemiplegia, encephalopathy, chronic systolic CHF, respiratory failure, altered cognitive function, insomnia, sleep apnea, hypertension, atrial fibrillation, abdominal aortic aneurysm, and a prosthetic heart valve, and was severely impaired for daily decision-making per the MDS. The activity assessment documented current interests in individual activities such as animals/pets, current events, exercise, movies, music, and family/friend visits, as well as interests in religious studies, shopping, sing-alongs, social parties, volunteering, walking, and arts/crafts. Past interests included bingo, cards, cooking, creative writing, dominoes, educational programs, and reading. The care plan indicated the resident was involved with activities some of the time, with goals to participate in activities of choice and remain active with individual activities, and interventions similar to those for Resident #28, including assistance to activities, encouragement, and provision of an activity calendar. Despite these documented interests and care plan interventions, the record for Resident #2 showed only a few one-on-one activities, such as two visits where staff sat and talked with the resident for 10–15 minutes and one in-room manicure. There were documented gaps with no evidence of any activities provided over extended periods between specified dates. Observations showed the resident frequently lying in bed with no activities present in the room, and the resident stated she did not go out of her room much and did not know what she was going to do that day. The Activity Supervisor acknowledged that only a few one-on-one activities were documented since admission and stated the resident had cognitive impairment, did not want to join other activities, and only came out of her room for meals. The Administrator confirmed there were no documented activities in the electronic medical record for these residents beyond the few noted, that the calendars for several months did not include scheduled one-on-one activities, and that there was little variety in daily activities. Additional information from Social Services indicated that a separate Medicaid "Quality Moments" program provided emotional/behavioral support to certain qualifying residents, but this service was not provided by facility staff, was not available to all residents, and was not part of the residents’ activity care plans. Observations also showed that an activity calendar for Resident #2 was posted on the wall but not within the resident’s view. Overall, surveyors determined that, based on observation, record review, policy review, and interviews, the facility did not ensure that residents were provided with an ongoing, individualized activity program consistent with their assessed preferences and the facility’s own Resident Activities policy.
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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