Failure to Provide Sufficient and Varied Resident Activities

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide activities that met a resident’s assessed needs, preferences, and cognitive capabilities. The resident had cerebral palsy, profound intellectual disabilities, seizures, hypertension, and dysphagia, with an MDS showing severe cognitive impairment and total dependence on staff for ADLs. The care plan dated 01/23/24 documented that the resident was dependent on staff for emotional, physical, spiritual, creative, and community activities, with goals to maintain involvement in cognitive stimulation and social activities and to participate in room visit programming two to four times weekly. Interventions included inviting the resident to scheduled activities, ensuring activities were compatible with physical and mental capacities and adapted as needed, and monitoring room visits and providing sensory-stimulating interventions. Activity documentation from January through March 2026 showed limited and infrequent activities for the resident, consisting mainly of occasional hand massages, being up in the living room, room visits, small chats, and one Valentine’s Day party and one instance of listening to music in the room. No other activities were documented beyond these few entries in each month. Observations on two separate days in March showed the resident sitting in a common area in front of a television, with no staff interaction noted and, at one time, no staff present while the resident and others watched television. In an interview, the Activity Director confirmed that the documentation from January to early March 2026 did not support that the resident was offered or provided activities as care planned for the resident’s preferences and needs, and that activities provided on some days were limited to being up in the living room, in the room with music on the television, and hand massages. This was inconsistent with the facility’s activity policy requiring an ongoing program based on each resident’s comprehensive assessment, care plan, and preferences.

Plan Of Correction

F0679 activities The POC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident # 40 has a new activities plan based on her particular needs utilizing the comprehensive assessment , care plan and preferences were done on 3-18-26 by the activities director. The new activities plan was created by the activities director on 3-18-26. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. Residents identified with similar cognitive and physical delays have been screened for appropriate activity plans. Residents who are identified with intellectual disabilities by diagnosis or low BIM scores and have community and individual activities ongoing to meet their needs. Sweep done 3-19-26. The activity director did the sweep and there were no negative concerns during the sweep. What measures will be put into place, or what systemic changes you will make to ensure that the deficient practice does not recur. The activities director was educated on 3-17-26 by administrator that the facility has an on-going program to support residents in their choice of activities, both facility sponsored groups and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community considering the residents level of functioning. How the corrective action will be monitored to ensure the deficient practice will not recur. Audits of proper activities began 3-19-26 The administrator/designee is auditing for activities that meet the needs of the residents with cognitive and intellectual delays, utilizing proper activity programming weekly X 4 weeks. Results being submitted to the QAPI committee. Concerns identified from the audit will be addressed, and the activity director will be further directed in proper activities by the administrator or classes.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide individualized activities of interest to a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, major depressive disorder, and ataxia. The resident’s annual MDS assessment documented severe cognitive impairment, dependence in ADLs, and that music, doing things with other people, and engaging in favorite activities were important to her. An activity preference assessment indicated she enjoys talking. The resident’s care plan stated she may continue to participate in group and/or 1:1 activities of her choice as tolerated. However, review of the medical record showed no evidence that she participated in 1:1 visits, and the activity department’s 1:1 list did not include her. During observation, the resident was found lying in bed with the bed against the wall and the TV positioned on the opposite wall, out of her view. She reported that activity staff do not visit her in her room. The Activity Director stated that activities are documented in the electronic chart and that she conducts 1:1 visits two to three times per week, and acknowledged that the resident had previously attended bingo but had been staying in bed due to pain in recent weeks. The Activity Director further revealed that activities staff did not conduct 1:1 visits with the resident while she was staying in her room, and there was no documentation that she was offered activities except for a Valentine’s Day celebration. The Activity Assistant confirmed she kept her own list of residents receiving 1:1 visits and verified that this resident was not on her list. The facility’s undated Activities Program policy stated that the facility will provide resident-centered care that meets the psychological, physical, and emotional needs and concerns of residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide and document resident activities during evening hours, particularly after 4:30 p.m., for residents with impaired cognition. Three residents with dementia or cognitive impairment had care plans and activity assessments identifying interests such as reading, watching television, being outdoors, socializing, and participating in group programs. Their plans of care included interventions like providing activity calendars, assisting and escorting to activities, offering materials for individual activities, and encouraging participation in groups. However, review of their electronic health records over a one‑month period showed no documented activity participation after 4:30 p.m. Surveyors also found that scheduled activities in the memory care unit were not consistently carried out as planned. The March activity calendar listed nail care and snacks/hydration in the afternoon, and repeated evening activities such as sensory boxes and movie and snack sessions. Observations showed that a scheduled nail care activity was not in progress at the designated time, and the snack and hydration activity was not completed as scheduled. Activity staff reported that only two activity staff worked and they left by 4:30 p.m. daily, and that floor staff on the memory care unit were assigned to complete and document evening activities. The Activity Director confirmed that activity participation documentation was silent after 4:30 p.m., that the scheduled activities were not followed on a specific date, and that she did not monitor charting to ensure staff documented resident participation, despite facility policy stating that the activity coordinator maintains individual participation records.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide activities that met individual residents’ assessed needs and preferences, and to make those preferences accessible to staff. For one resident admitted with COPD, bipolar disorder, alcohol dependence, and hypertension, the admission activity assessment documented that he did not respond to questions and there was no evidence that family was contacted to obtain preferences. His care conference indicated activity staff were to offer group activities and review the monthly calendar, yet activity documentation from admission through the first week showed only a single one-on-one “chatting” interaction by a nurse aide and no evidence he had been invited to group activities. Multiple observations over several days showed this resident either in bed or in a wheelchair in the hallway with no entertainment, even when craft activities were occurring in common areas. Activity staff later stated they were unable to document any activities for him and had no evidence he had participated in or been invited to activities since admission. Another resident, cognitively intact and with multiple chronic conditions including chronic respiratory failure, morbid obesity, COPD, sleep apnea, and several psychiatric diagnoses, was assessed as preferring room visits three times per week and not wanting to participate in activities outside her room. However, the assessment did not document that she was asked about interest in community activities. Activity logs over a three‑month period showed no activities outside her room and no community activities. Observations on several dates showed her lying in bed with no staff approaching to ask about activity participation. In interview, she confirmed that no community activities were offered and stated she would love to go out to eat or go shopping but that this was never offered. Activity staff confirmed they did not have access to residents’ activity assessments, were unsure of individual preferences unless residents told them directly, and that no community activities were scheduled; review of facility activity calendars over three months showed no community activities. A third resident with vascular dementia, anxiety disorder, and muscle weakness had an activity assessment and care plan indicating she did not wish to participate in group activities but preferred independent activities such as listening to music, doing word searches, attending church services, and receiving music, word search books, and crafting supplies. Observations over two days at multiple times showed her sitting in her room without any of her preferred independent activity items provided. Activity staff interviews revealed that one‑on‑one documentation was kept on paper in a book held by the activity coordinator, that individual preferences were obtained from the Activity Director or by learning from staff and residents, and that no activities had been provided for this resident during the week. A fourth resident with major depressive disorder, generalized anxiety disorder, schizoaffective disorder (including bipolar type), dementia, and restlessness/agitation had a care plan directing staff to encourage attendance at activities of interest and to provide preferred activities such as bingo, dancing, singing, writing and solving math problems, and going outside, while noting that the resident did not like coloring or drawing. Observations over two days showed this resident in their room with the door shut and not participating in activities while other residents in the common room engaged in coloring and drawing. Review of the resident’s activity task documentation over 30 days showed that activities offered were predominantly coloring, crafts, “chit chat,” or art, with participation often passive or refused. A 90‑day review of one‑on‑one activity documentation showed activities were not consistently offered and often recorded generic entries such as the resident being out of the room or “morning news,” with no entries for bingo, music, dancing, or outdoor activities. Activity staff reported that if residents did not want group activities they would offer one‑on‑one interactions such as talking or hand massages, that this resident struggled with group activities and was given one‑on‑ones, and that they identified music and talking as interests. Staff also confirmed they lacked access to residents’ activity evaluations, used paper tracking for some one‑on‑ones, and that community activities were not being conducted. The facility’s Activity Programs policy stated that programs are to be geared to individual needs and reflect residents’ schedules, choices, rights, interests, hobbies, and personal preferences, which was not supported by the documented practices and observations. The Administrator confirmed that the facility did not have consistent activity logs to verify when activities occurred and which residents participated. Activity staff further confirmed that they did not have access to residents’ activity evaluations to identify preferences and that some one‑on‑one activities were tracked only on paper for certain residents. Across the four residents reviewed, surveyors found a pattern of missing or incomplete assessment follow‑through, lack of documented invitations to activities, absence of preferred or community activities, and reliance on limited or generic activities such as coloring and crafts that did not align with documented or expressed preferences. These findings demonstrated that the facility failed to ensure activity preferences were available to aides and failed to complete activities according to resident preferences, contrary to its own Activity Programs policy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide activities that met all residents’ needs and to maintain adequate activity staffing. Resident Council minutes documented residents reporting that activities were being cut short due to insufficient staff and that live musical entertainers were no longer provided. The Administrator responded that activities were not being shortened because of staffing and explained that entertainers were now required to have a tax identification number to be issued a 1099, and that no entertainers were willing to comply. Review of activity calendars for several months showed only one facility-wide calendar with no separate programming for residents with cognitive impairments, limited variety in scheduled activities, and very few one-on-one or independent activities/room visits. Activities were largely repetitive, consisting of daily coffee and discussion with distribution of the Daily Chronicle, weekly Bible study and church services, and bingo three times per week. Interviews and observations showed that activity staff were being used for non-activity tasks and that residents with higher needs were discouraged from attending group activities. An activities staff member reported that the facility previously had pastors come in for Sunday services but now relied on televised services, and a resident expressed a desire for more religious services, particularly Catholic, stating that television services were not interactive. Observations showed an activities assistant hurriedly delivering the Daily Chronicle with minimal interaction and later spending nearly two hours going room to room obtaining menu selections for the next day’s meals. Multiple residents and staff reported that the activities department lacked sufficient staff, that one activity aide was routinely diverted to pass snacks and obtain menus, and that staff had been told by the Administrator not to bring residents to group activities if they needed help, as it was considered unfair to other residents. Anonymous employees stated that residents who were not cognitively intact or were significantly disabled were not to attend activities like bingo if they could not participate independently, and that in-person religious services had not occurred for approximately two months. Specific residents’ records and observations further demonstrated unmet activity needs. One resident with severe dementia, anxiety, depression, insomnia, and impaired mobility had a care plan calling for daily one-on-one room visits by activity staff to promote socialization and reduce boredom, but electronic records for three consecutive months showed no documentation that these visits occurred. Another resident with moderate dementia, anxiety, difficulty walking, and anorexia had a similar care plan for daily one-on-one room visits, also without any documented completion over the same three-month period. During a bingo activity observed with about 20 participants, two activity assistants were present, but one resident sat with eyes closed and no active participation despite having a bingo card and chips, and two cognitively impaired residents were seated without adequate assistance; one was not given a bingo card or chips and continuously chewed on a blanket, and another could not follow the game despite having a card and chips. An employee reported that there was room for improvement in activities, that there were not enough activities, residents were bored, and residents felt their activity suggestions were not being considered. These findings contrasted with the facility’s written activities policy, which stated that activities would reflect residents’ cultural and religious interests and be person-appropriate, with accommodations in schedules, supplies, and timing to optimize participation.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide meaningful and preferred activities for residents on the secured unit, specifically for Resident #9 and Resident #11, despite identified preferences and care plan interventions. Resident #9, admitted with dementia, major depressive disorder, anxiety, and other medical conditions, had a BIMS score indicating intact cognition and a care plan stating the resident felt it was important to listen to music, be around animals, watch TV, play bingo, socialize, go outside in good weather, and attend religious services. The care plan directed staff to invite, encourage, and assist the resident to activities of interest and to provide supplies for independent leisure activities. Activity calendars showed that music, religious services, food activities, and bingo were regularly scheduled, but participation records for December showed Resident #9 did not attend any music or religious activities, only some food and bingo events, and observations during survey showed the resident in common areas without involvement in any structured or independent activity. Interviews with staff confirmed that the secured unit did not have an assigned activity person and that activity staff did not go to the secured unit to conduct activities. The Activity Coordinator stated that only three or four residents who could sit for 15 to 30 minutes were brought off the secured unit for activities, and verified that residents on the secured unit did not participate in certain scheduled activities such as bread day, although bread was passed to them. The Program Director for the secured unit stated that “Social Circle” on the activity log could mean puzzles, crafts, coloring, or other various activities, and that movies and watching TV were considered the same activity. The Program Director further stated that music was played during meals and the TV was on the rest of the time, and that these were considered daily activities for Resident #9, along with talking and interaction in common areas. However, the Program Director also verified there were no daily, structured activities on the secured unit and that nursing staff only did activities when able. For Resident #11, who was legally blind with a cognitive communication deficit, difficulty walking, and high blood pressure, the activity care plan documented that it was important to him to listen to music, keep up with the news, participate in group activities, go outside, attend religious services, and have snacks between meals. Review of daily activity logs over several weeks showed that the only documented music exposure occurred when musical entertainment performed at the facility, and there was only one entry for crafts, with no entries indicating that the resident listened to music or kept up with the news as preferred. Multiple observations over several days found Resident #11 lying or sitting in a recliner in a common area near the front desk and main entrance, or resting in bed, without music or TV playing. The Activity Coordinator confirmed that the resident had been seated in the common area for the past two days with no music or news playing, despite these being documented as important activity choices for him. The facility’s policy on Resident Activity Preferences stated that the facility would accommodate resident activity preferences through the comprehensive assessment and care planning process, which was not followed in these cases.