Failure to Provide Individualized Activities and Document Participation
Summary
The facility failed to provide an ongoing activities program designed to meet the interests, physical, mental, and psychosocial well-being of 7 of 10 sampled residents. Facility policy stated residents had the right to participate in an activities program designed to meet their needs, and the Activities Program policy stated the facility would provide ongoing activities in accordance with residents’ interests and well-being, including 1:1 programming for residents unable or unwilling to attend group activities and staff assistance with transportation to and from activities. Resident #5 had diagnoses including CHF, chronic pulmonary edema, cognitive communication deficit, and hypertension, and an MDS BIMS score of 4 indicating severe cognitive impairment. The care plan directed simple, structured activities and reminiscence with family photos, but there was no documentation that activities were provided or offered for the month reviewed. The resident’s representative stated he loved bingo but was unsure whether he was getting to go, and the resident stated he used to play bingo and enjoyed it. During observation, no TV was playing and no radio was beside the bed for music stimulation. Resident #9 had Alzheimer’s disease, anxiety disorder, and major depressive disorder, with an MDS showing poor short- and long-term memory recall. The care plan called for low-functioning activity programming, 1:1 sessions, sensory and environmental stimulation, and diversionary activities, but there was no documentation of activities being provided or offered during the review period. The resident was observed sleeping or lying in bed facing the wall on multiple occasions, with no TV on and no radio beside the bed. Resident #22, who had Alzheimer’s disease, vascular dementia, anxiety disorder, and major depressive disorder, had a BIMS score of 14 and a care plan calling for simple structured activities and a program accommodating abilities, yet there was no documentation of activities being provided or offered, and the resident was observed sleeping with no TV or radio present. Resident #26, with diabetes mellitus, cognitive communication deficit, and major depressive disorder, had a BIMS score of 12 and a care plan for friendly visits and diversionary activities, but there was no documentation of activities being provided or offered; the resident stated she slept most of the day and did not think the Activity Director came by or talked with her, and no radio was present. Resident #29 had anemia, hyperlipidemia, hypertension, and anxiety disorder, with a BIMS score of 14 and a care plan noting interests in walks outside, people watching, games, bingo, baking, volunteering, and courtyard time. There was no documentation of activities being provided or offered, and the resident stated there was nothing to do on weekends, that she wanted to go outside but no one could go with her, and that going out with smokers was undesirable. Resident #41 had hemiplegia and hemiparesis following cerebral infarction, major depressive disorder, and anxiety disorder, with a BIMS score of 10 and a care plan for low-functioning activity programming and reminiscence, but there was no documentation of activities being provided or offered; the resident was observed sleeping in bed with no TV or radio. Resident #54 had hemiplegia and hemiparesis, cerebral infarction, major depressive disorder, and anxiety disorder, with a BIMS score of 14 and a care plan for reminiscence, but there was no documentation of activities being provided or offered, and the resident was observed sleeping with no TV or radio. During interview, the Activity Director stated CNA staff charted activities in the electronic system, but when asked for activity participation over the last month, she produced handwritten sheets listing resident names and dates only, without the activity provided or resident response, and stated that without documentation she could not prove it happened. She also stated weekend activities were attempted by management but were not charted. The SSD stated CNAs had an activity tab to chart, and residents had complained about no weekend activities and about wanting to go outside without having to go around smokers. The DON acknowledged that residents who do not attend group activities should be provided 1:1 activities and stated residents who request to go outside should be allowed to go out.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Provide Resident-Centered Activities Three residents did not receive an ongoing activities program matched to their needs and preferences. A resident with severe visual impairment was bored on weekends and could not participate in bingo because he was not given a large-print card. Another resident said she was never asked about activity preferences, did not get an activity calendar until later, and was not offered in-room activities. A third resident with significant neurologic and physical impairments said preferred activities were unavailable and he was bored; the acting AD reported activities often started late and many residents could not participate.
Failure to provide activities for a resident with Parkinson’s disease, cerebrovascular disease, moderate cognitive impairment, and dependence in ADLs/transfers. The resident was repeatedly observed in bed in a quiet room without stimulation while music, art, and worship activities were available, and records showed only limited 1:1 visits with no documentation of activity attendance or refusal. The AD noted the resident liked music and art and had not been out of the room for an activity since March.
Failure to Provide Individualized Activities: A resident with anxiety, depression, and weakness was cognitively intact but said they could not attend group activities because of leg problems and wanted more in-room activities. The resident mostly stayed in bed watching TV, and staff documentation showed only limited room visits with no consistent activity documentation despite a care plan goal for participation two to three times per week.
Failure to provide individualized activities for a resident with dementia. The resident's representative said the resident had not received activities and needed to stay busy, while survey observations showed the resident wandering in the halls and sitting in the lobby without participating in facility activities. The DON reported there was no record of activity participation, and an activity staff member said she only talked with the resident occasionally and was the only activity staff member, so she did not have time.
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 stroke, vascular dementia, and kidney failure was non-verbal and unable to make needs known, yet the facility did not develop or implement an individualized activity plan. The care plan had incomplete activity focus, goals, and interventions, and activity flow sheets showed the resident was not offered or participated in any individual or group activities. Observations showed the resident lying in bed awake looking at the ceiling or wall, with the TV in the room not on during the observations.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide an ongoing activities program that supported residents’ choices of facility-sponsored group activities, individual activities, and independent activities for three residents reviewed for activities. The deficiency involved Resident #27, Resident #73, and Resident #85, and the report states that the failure could place residents at risk for boredom, depression, and diminished quality of life. Resident #27 was an older male with diagnoses including blindness in both eyes and a BIMS score of 6, indicating severe cognitive impairment. His MDS reflected that vision was highly impaired and that books, newspapers, and magazines were very important to him. His care plan addressed visual impairment and legal blindness, but there was no activities focus. During interview, he said he got bored on weekends because there were not enough activities, especially activities that accommodated blindness. He also said he was taken to bingo but was not given a large-print bingo card, so he could not participate. Resident #73 was a female with diagnoses including a displaced comminuted fracture of the shaft of the right femur, atrial fibrillation, and morbid obesity, and her BIMS score was 15. Her baseline care plan had no activities focus. She stated she was not asked about activity preferences on admission, did not receive an activity calendar until later, and no one had come to her room to offer activities such as coloring materials or puzzles. Resident #85 was a male with diagnoses including central cord syndrome at C3, occlusion and stenosis of an unspecified middle cerebral artery, and a cerebral aneurysm, with a BIMS score of 9. His care plan noted dependence on staff for activities and cognitive stimulation/social interaction related to physical limitations. He said the facility had asked what activities he liked, but the toss game they used to play outside could not be located, popcorn was no longer available during movies, and he was currently bored. The acting AD stated activities did not always start on time, there was not much resident involvement because many residents lacked physical ability or stamina, and she had no training in being an activities director or direction from the facility regarding activities.
Failure to Provide Activities for a Resident with Cognitive and Physical Impairment
Penalty
Summary
The facility failed to provide activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of Resident 22. The resident’s diagnoses included Parkinson’s disease and cerebrovascular disease. The Quarterly MDS dated 2/10/26 indicated moderate cognitive impairment and dependence in ADLs and transfers. The Activities Care Plan, revised 4/27/26, directed staff to invite the resident to groups of interest such as worship, music events, social groups, and cognitive groups. During random observations, Resident 22 was repeatedly found lying in bed in a quiet room without television, music, or other stimulation on multiple dates and times. On 5/1/26, while a live music activity was occurring in the main dining room, the resident remained awake in bed in his room. The May 2026 Activities Calendar listed music, art, and worship activities, but the Activities Participation 30-day documentation showed only three one-on-one visits per week, one friendly visit, and one people watching entry, with no documentation that the resident attended or refused activities. The Activities Director stated the resident liked music and art, had previously participated with assistance, had not been out of his room for an activity since March, and that the only activity interaction he was receiving was three 20-30 minute one-on-one visits per week.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to provide individualized activities for Resident 5, who was admitted with diagnoses including anxiety disorder, depression, and weakness. The admission MDS dated 01/14/2026 showed the resident was cognitively intact. During interviews on 05/03/2026 and 05/06/2026, Resident 5 stated they could not attend in-person activities because of their legs, wanted more activities to occupy them, mostly stayed in bed watching TV, and did not remember the last time activities staff visited to offer activities. The resident also stated activities staff would need to offer something they were able to do because they had difficulty doing some activities. The activities care plan dated 12/26/2026 showed a goal for Resident 5 to participate in activities two to three times per week. Progress notes documented one visit on 12/22/2026 to provide a welcome packet and encourage participation in daily activities, but no further activity documentation was found in the progress notes. Staff H stated room visits should include puzzles, arts and crafts, visiting, and chatting, and that documentation was placed in tasks, but the task record showed no documentation of activities for the past 30 days. Staff J stated paper documentation existed for room visits and that Resident 5 was on a list for room visits every Monday and Wednesday, while the room visit documentation showed only four visits on 01/26/2026, 02/06/2026, 03/10/2026, and 04/08/2026.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to ensure individual activities of preference were provided to a resident with Alzheimer's disease who was identified in the care plan as being at risk for depression and impaired social interaction and who was expected to participate in social situations and activities of choice. The resident's representative stated the resident had not received activities at the facility and needed to stay busy because of dementia, and reported that attempts to speak with activity staff about appropriate activities were unsuccessful because staff were always on their way somewhere else. Survey observations showed the resident wandering in the halls and sitting in the front lobby, and the resident was not observed participating in facility activities. The DON stated there was no record of activity participation for the resident, and an activity staff member stated she only sat and talked with the resident once in a while and was the only activity staff member, so she did not have time. The facility policy also stated that special considerations would be made for developing meaningful activities for residents with dementia and/or special needs.
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.
Incomplete individualized activity plan and no documented activity participation
Penalty
Summary
Provide activities to meet all resident's needs. Based on observation, interview, and record review, the facility failed to develop and implement an individualized activity plan for Resident 61, who was admitted with diagnoses of stroke, vascular dementia, and kidney failure and was non-verbal and unable to make needs known. The resident's care plan had incomplete activity focus, goals, and intervention areas. Observations on 04/20/2026, 04/21/2026, and 04/22/2026 showed the resident lying in bed awake looking at the ceiling or wall, with a television present in the room but not observed on during any of the observations. Review of the March and April 2026 activity flow sheets showed the resident was not offered and did not participate in any individual or group activities. During interview, the Activity Director reviewed the record and stated staff should have contacted the resident's representative to assist with the activity care plan and that the resident had not been offered any independent or group activities, which did not meet expectations.
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