Failure to provide individualized activity programs for 3 residents. Residents with preferences for independent or one-to-one activities, including interests such as music, TV, arts and crafts, reading, bingo, and going outside, had care plans and activity calendars that listed personalized opportunities, but there was no documentation they were offered or participated in them. The Activities Director acknowledged the facility lacked a meaningful program for residents unable to attend group activities, and residents reported boredom, lack of offers, and little activity in their rooms.
Failure to Provide Person-Centered Activities: A resident with stroke and dysphagia had care-planned interests including group activities, music, pet visits, and outdoor time, but activity records showed no self-directed activities or activity visits and only limited conversation/reminiscing documented. Staff were unfamiliar with the resident’s activity plan, and the Activity Director confirmed the resident had not been offered additional activities beyond TV and music.
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 Meaningful Activities Based on Resident Preferences A resident with dementia, cognitive impairment, and limited English was not provided meaningful activities based on stated preferences for gardening, music, animals, and going outside. Records showed limited participation, while most activity logs documented keeping up with the news, which was not preferred. Observations found the resident in bed or wandering in a wheelchair with no activity materials available, and staff confirmed no one-on-one, group, or preference-based activities were provided.
Failure to provide meaningful activities for a resident with severe cognitive deficits, encephalopathy, and bipolar disorder. The resident preferred reading, music, sports, cooking shows, walks, and group or 1:1 activities, but records showed only two TV/movie entries and no evidence of magazines, books, newspapers, music, walks, or other preferred activities. Observations found the resident in a dark room, mostly in bed, with no stimulation, and staff stated they did not recall providing 1:1 activities or other activities of interest.
Failure to provide resident-requested activities and outings: Several cognitively intact residents with diagnoses including Parkinson's disease, HF, DM, anxiety, and depression repeatedly asked for bus rides, shopping, fishing, park trips, and other community outings, but council notes and staff interviews showed outings had not occurred for months. Staff acknowledged the bus was available, only one staff member was approved to drive it, and residents' requests remained unresolved, with residents describing activities as boring and lacking social events.
Failure to Provide Person-Centered Activities: A resident with quadriplegia and DM2 had a care plan calling for individualized, in-room activities such as Bible study, music, reading materials, and one-to-one visits, but records showed no documented activity engagement over a 30-day period. Observations found the resident in bed watching TV without activity materials in the room, and staff reported no observed in-room or individualized activity support from the activity dept.
Failure to provide meaningful activities for a dependent resident. A resident with brain damage and HF was unable to complete BIMS, had activity preferences completed by staff, and was identified as needing appropriate activities to help protect against social isolation and loneliness. The care plan listed socializing with staff and watching comedy in a chair, but activity involvement showed only one one-to-one conversation in 30 days and no other activities. Staff observed the resident in bed with the TV on and no engagement, and staff reported infrequent family visits, limited chair time, and lack of training in caring for cognitively impaired residents.
A resident with Parkinson’s disease and severe cognitive impairment did not receive an ongoing person-centered activity program. The care plan listed preferred activities such as music, bingo, and visiting with others, but records showed only two documented one-to-one visits over several months and no evidence of out-of-room activities or socialization. Observations found the resident often in bed with the TV off or playing unwanted music, and staff interviews showed limited awareness of the resident’s preferences and infrequent activity engagement.
Failure to Provide Resident-Centered Activities: A resident with anxiety, post-stroke dysphagia, cognitive impairment, and dependence for all ADLs/mobility had documented interests in music, birds, outdoor time, family calls, sensory visits, and 1:1 visits, but was repeatedly observed in bed with little accessible leisure support. Staff described the resident as mostly liking TV, yet the resident said Western programs were not liked and stated being bored; the AD noted no set schedule for 1:1 visits, no group activity attendance in over a year, and no music or other leisure opportunities in the room.
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