Lack of individualized and evening activity programming: The facility did not provide an ongoing activity program that matched residents’ interests and choices, and it did not provide 1:1 activities for a resident identified as needing them. Residents reported no evening activities, repeated programming, limited variety, and little staff encouragement to participate. One resident with multiple chronic conditions and another with cognitive impairment wanted more meaningful activities, while a cognitively intact resident with CVA, paraplegia, and depression said staff did not regularly offer time out of bed or room-based engagement. The AD stated she did not have a 1:1 list, and the calendar showed no evening activities.
Failure to Provide Ongoing Activities for Memory Care Residents: Three residents with dementia-related diagnoses and documented activity preferences were not consistently offered or engaged in activities on the memory care unit. Records showed only limited participation in scheduled events, while observations found no visible activity schedule in the common area, no observed resident activities during multiple checks, and residents sitting unattended. Staff and family interviews described limited supplies, inconsistent activity delivery by aides, and no routine one-to-one activities unless specifically in the care plan.
Failure to Provide Resident Activities: A resident with severe cognitive impairment and care plan interventions for one-on-one room visits had only one brief documented interaction, while two cognitively intact residents reported that too few activities were offered and that many were babyish. Observations showed no activities on the 300 hall, and scheduled programs on [NAME] Hall did not occur as listed on the activity calendar. Staff and the DON confirmed activities were not being completed consistently, with the AD reporting short staffing and competing duties.
Lack of Staff-Led Weekend Activities: Three residents stated they enjoyed activities but there were no weekend activities, leaving them bored, lost, or just laying in bed. The activity calendars showed only limited weekend options such as puzzles, books, TV, and church, and the activities director, CNA, LPN, DON, and administrator all confirmed there were no staff-led weekend activities.
Surveyors found that the facility did not complete activity assessments or develop care plan interventions for multiple residents with conditions such as dementia, bipolar disorder, stroke, MS, and schizophrenia, despite a policy requiring individualized activity programming. An outdated activity calendar was posted, but no group activities were observed over several days, and several cognitively intact residents reported that there were not enough activities, that they were bored, and that activity staff were insufficient. Some residents described doing nothing all day except for medical appointments or paying out-of-pocket for outings. Records for residents identified as needing 1:1 activities showed they were scheduled on specific days, yet there was no documentation of 1:1 activities being offered or provided, and observations confirmed these residents were not engaged in such activities. The Activity Director stated she had just started employment and had not yet created a current calendar or begun 1:1 activities, while the Administrator and DON stated they expected activities and 1:1 services to be provided and reflected in care plans.
The facility failed to provide individualized, resident-centered activities to meet the psychosocial needs of two residents with serious mental illness. Facility policy required assessment of resident interests, posting of activity calendars, and daily documentation of participation, but calendars were not posted, resident preferences were not clearly identified in care plans, and attendance records were incomplete. One resident, cognitively intact with schizophrenia, anxiety, and bipolar disorder, reported boredom, wanted activities beyond coloring and BINGO and opportunities to go outside, and was sent to the ER after expressing suicidal thoughts later attributed to boredom; staff acknowledged limited activities, especially at night and on weekends, and that the resident had not been specifically asked about preferred activities. Another resident with psychosis and bipolar disorder, with a PASRR Level II requiring a structured schedule, reported there was nothing to do, preferred 1:1 rather than noisy group activities, and had minimal documented activity participation over several months, while the Activity Director stated not knowing the resident’s interests and not consistently documenting attendance.
Incomplete activity participation and progress documentation: A resident with stroke, dementia, anxiety, and MDD had an activity care plan calling for scheduled group and individual activities, but daily participation records were missing for two months and quarterly activity notes were incomplete or absent. The resident’s family and CNA/LPN staff said the resident often stayed in the room with the door shut unless staff informed and encouraged participation, while the Activities Director reported missing documentation from the prior AD and the DON said participation should be documented after each activity or at least daily.
Residents did not receive a consistent weekend activity program to meet their interests and psychosocial needs. Multiple residents said there were no staff-led activities on weekends and that they spent time watching TV, coloring, reading, or staying in their rooms. Staff, including the AD, DON, RN, NA, and administrator, confirmed that weekend activities were limited to coloring pages, occasional games if aides had time, and church services, with no scheduled staff member responsible for leading activities.
Failure to provide an ongoing activities program and resident-specific activity assessments. The SCU had no posted activity calendar, no activity supplies, and no observed activities, and staff said the unit had not been receiving activities because the activities staff were pulled to the floor or absent. Two residents with dementia-related conditions had care plans referencing activities, but their records lacked documented activity assessments and attendance, and observations showed them sitting alone, disengaged, or displaying behaviors without activity involvement.
Resident-centered activities were not implemented for two residents with impaired cognition and documented interests, and a third resident who had severe cognitive impairment, anxiety, and behaviors was not placed on one-to-one activities. Residents on The Loop reported too few activities, observations showed no activities in progress at multiple times, the activity calendar did not identify locations, and staff described activities as inconsistent and not meaningful. The Activities Director had not assessed the resident who needed one-to-one support, and the resident remained in bed in a dark room wearing a hospital gown while yelling loudly.
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