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 resident with dementia, severe cognitive impairment, depression, visual and hearing impairments, and other comorbidities had documented preferences on the MDS for reading materials, music, and being around animals, but the activity assessment was completed only with the resident, not family, and concluded the resident could not identify preferred activities. The care plan inconsistently described the resident as sociable with interests in arts and crafts, bingo, and music, yet noted no current activities of interest, and a later activity participation review was left incomplete. Activity records listed daily relaxation and media-based activities and one-on-one reading, but staff later clarified that relaxation meant the resident was simply resting in bed and that recorded one-on-one sessions did not actually occur because the resident was asleep. Surveyors repeatedly observed the resident awake in a dark room with no television, music, reading materials, or other entertainment, and staff were unable to state the resident’s specific activity preferences, demonstrating a failure to adequately assess and implement individualized activity services.
A resident with multiple chronic conditions and frontotemporal neurocognitive disorder, who was dependent on staff to meet emotional, intellectual, physical, and social needs, did not receive individualized activities consistent with documented preferences. The activity assessment showed the resident was Catholic, valued pets and sports, and was interested in various group and leisure activities, yet observations found the resident repeatedly in a dark room with only television for stimulation. Activity staff reported the resident often refused activities but admitted they did not document what was offered or refused, had limited activity documentation, could not access the activity assessment and care plan, and were unaware of the resident’s religious affiliation and specific entertainment preferences.
Surveyors found that the facility failed to provide adequate, individualized activities for all residents on the memory care unit. The activity calendar showed only repetitive offerings such as juice, news, and table talk daily, with a single weekly morning stretch. Observations revealed multiple residents sitting in the dining room or in recliners with only television music and no structured or spontaneous activities, and an activity aide distributed word searches only to residents at the table, not to those in recliners. A CNA reported that residents were not offered mental stimulation between scheduled activities. The activity aide stated that a blind resident was not offered adapted activities, and that two other residents who wandered or became easily agitated were also not offered activities, despite facility policy requiring diverse, adapted programming.
A resident with cerebral palsy, profound intellectual disabilities, severe cognitive impairment, and total dependence for ADLs had a care plan calling for individualized, cognitively stimulating, and social activities, including room visits two to four times weekly and adapted activities based on assessed needs and preferences. Over several months, activity documentation showed only sporadic hand massages, occasional time sitting in a common living room, brief room visits, a single holiday party, and one instance of listening to music, with no evidence of consistent, care-planned programming. Surveyor observations twice found the resident sitting in front of a television in a common area without staff interaction. The AD confirmed that records did not support that the resident was offered or provided activities as outlined in the care plan, despite a facility policy requiring an ongoing, individualized activity program.
A resident with Alzheimer's disease, major depressive disorder, ataxia, severe cognitive impairment, and dependence in ADLs had documented preferences for music, social interaction, and favorite activities, and a care plan allowing participation in group and 1:1 activities as tolerated. Despite this, there was no evidence in the medical record or 1:1 activity lists that she received 1:1 visits, and she reported that activity staff did not visit her room. She remained in bed with the TV out of her view and had only one documented activity offer related to a holiday event, while both the AD and an activity assistant confirmed she was not included on their 1:1 visit lists, contrary to the facility’s activities program policy.
The facility failed to provide and document evening activities for several cognitively impaired residents whose care plans identified specific activity interests and needs for assistance and verbal prompts. Activity records over a month showed no participation documented after 4:30 p.m., even though the activity calendar listed afternoon and evening programs such as nail care, snacks/hydration, sensory boxes, and movie and snack sessions in the memory care unit. Observations revealed that scheduled activities were not occurring at the designated times, and staff acknowledged that activities were not completed as planned and that documentation after 4:30 p.m. was not monitored, despite policy assigning responsibility for maintaining individual participation records to the activity coordinator.
Failure to Adequately Assess and Implement a Resident’s Activity Preferences
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and honor a resident’s activity preferences and to meet the resident’s identified needs for meaningful activities. The resident had dementia, severe cognitive impairment with a BIMS score of six, depression, age-related macular degeneration, osteoarthritis, and sensorineural hearing loss. The comprehensive MDS assessment documented that it was somewhat important to the resident to have books, newspapers, and magazines to read, to listen to music, and to be around animals such as pets. Despite this, the activity participation assessment dated 10/06/25 noted the resident was hard of hearing and hard to communicate with, was completed only with the resident and not the family, and concluded the resident was unable to identify preferred activities. The plan of care dated 11/06/25 described the resident as sociable, liking to participate in various activities, and willing to interact with others and participate in activities related to their interests as their condition allowed. It also stated the resident had no current activities of interest and was unable to pursue interests due to physical and/or cognitive condition, while listing arts and crafts, bingo, and music as important activities. Interventions included discussing the activity calendar, encouraging rest so the resident could attend preferred activities, and inviting the resident to music-related and scheduled activities. However, the subsequent activity participation review dated 12/15/25 was not completed, and the Activities Director reported trying to identify the resident’s preferred activities but could not refer to any documentation of this, and thought she had spoken to the family but acknowledged it might not be documented. Activity participation records from 04/01/26 to 04/19/26 showed daily participation in relaxation, television/radio/movies, and news events, and documented one-on-one and reading activities on two dates, although the Activities Assistant later stated the resident had been asleep during those one-on-one sessions and that relaxation meant the resident was simply resting in bed. Multiple observations on 04/20/26 and 04/21/26 found the resident awake in a dark room with no television, music, reading materials, or other entertainment, and an empty bedside table. A CNA confirmed the resident was sitting in the dark without any form of entertainment and was unsure of the resident’s music or television preferences. The RAI User’s Manual guidance cited in the report states that activity preference information should be obtained from the resident or, if not possible, from family or others, and used to create an individualized plan based on the resident’s preferences, underscoring that the facility did not adequately assess and implement the resident’s activity preferences as required.
Failure to Provide and Document Individualized Activities for a Dependent Resident
Penalty
Summary
The facility failed to ensure that one resident received appropriate, individualized activities and that activity offerings and refusals were properly assessed, care planned, and documented. The resident was admitted with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction, dysphagia, chronic heart failure, type 2 diabetes mellitus, and frontotemporal neurocognitive disorder. A quarterly MDS assessment indicated the resident was rarely or never understood, and the plan of care documented that the resident was dependent on staff to meet emotional, intellectual, physical, and social needs, with interventions such as introducing the resident to others with similar interests, inviting to scheduled activities, and providing a program of activities of interest. An activity evaluation identified that the resident was Catholic, actively participated in religion, and that pets and sports were very important, while board games, community outings, current events, cultural events, educational programs, visits, group discussions, movies, music, television, and radio were somewhat important. The evaluation also noted the resident was interested in activities and was cooperative and cheerful. Observations over multiple days showed the resident in a dark room with no entertainment on one morning and only watching television at other times, with no evidence of other activities being offered that matched the documented preferences. During interviews, an activities assistant stated the resident refused many activities and did not like what was offered, but acknowledged that the activities offered and refused were not documented and that there was limited activity documentation overall. In a subsequent interview, two activities assistants reported they knew the resident liked trivia but were unable to access the activity assessment and care plan and were unsure of specific preferences such as what television and music the resident enjoyed. They were also unaware of the resident’s Catholic faith, despite the activity evaluation documenting this and noting that Catholic visitors came to see residents, indicating the resident had not been added to that list.
Failure to Provide Adequate, Individualized Activities on Memory Care Unit
Penalty
Summary
The deficiency involves the facility’s failure to provide activities that met the needs and cognitive capabilities of residents on the memory care unit, affecting 24 residents. Review of the March 2026 memory care activity calendar showed that scheduled programming for one week consisted only of “juice and news” and “table talk” every day, with “morning stretch” offered only once weekly. Observations on multiple days showed residents sitting in the dining room with only music playing on the television and no other structured or spontaneous activities provided, despite the facility’s policy stating that memory care programming would offer a diverse variety of events throughout the day, with activities adapted and modified based on resident abilities and dementia progression. On one observed morning, five residents were seated around the dining room table with only television music available. On another morning, seven residents were seated in the dining room with only television music until an activity aide began distributing word searches to residents at the table, while three other residents remained in recliners in front of the television and were not offered any activity. A CNA from agency who frequently worked on the memory care unit stated there were no activities for residents and confirmed residents were not offered mental stimulation between scheduled activities. The activity aide reported that one resident was blind and therefore was not offered activities beyond sitting next to the aide, acknowledged that this resident should be offered alternative activities, and stated that two other residents who wandered or became easily agitated were also not offered activities, and in one case the aide did not know the resident’s name.
Failure to Provide Care-Planned, Individualized Activities for a Dependent Resident
Penalty
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.
Failure to Provide Individualized 1:1 Activities for Bedbound Resident
Penalty
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.
Failure to Provide and Document Evening Activities for Cognitively Impaired Residents
Penalty
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.
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