Tammie Martin, MHA, CTRS
Activities Director F249
(2) The activities program must be directed by a
qualified professional who(i) Is a qualified therapeutic recreation specialist or
activities professional who(A) Is licensed or registered, if applicable, by the State in
which practicing; and
(B) Is eligible for certification as a therapeutic recreation
specialist or as an activities professional by a
recognized accrediting body on or after Oct. 1, 1990;
or
(ii) Has 2 years of experience in a social or
recreational program within the last 5 years, 1 of
which was full time in a patient activities program
in a healthcare setting; or
(iii) Is a qualified occupational therapist or
occupational therapy assistant; or
(IV) Has completed an approved training course
approved by the State.
Activities F248
(f) Activities
(1) The facility must provide for an
ongoing program of activities designed to meet,
in accordance with the comprehensive
assessment, the interests and the physical,
mental, and psychosocial well-being of each
resident.
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19CSR 30-85.032(93) The facility shall designate
an employee to be responsible for the activity
program.
• The designated person shall be capable of
identifying activity needs of residents, designing
and implementing a program to maintain or
increase, or both, the resident’s capability in
activities of daily living.
• Facilities shall provide activity programs on a
regular basis.
• Each resident shall have a planned activity
program which includes individualized activities,
group activities and activities outside the facility
as appropriate to his/her needs and interests.
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(94) The facility shall provide and use
adequate space and equipment within the
facility for the identified activity needs of
residents.
(95) The facility shall establish and maintain a
program for informing all residents in
advance of available activities, activity
location and time.
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19 CSR 30-86.047(31)(A) The facility shall
designate a staff member to be responsible
for leisure activity coordination and for
promoting the social model, multiple staff
role directing all staff to provide routine care
in a manner that emphasizes the opportunity
for the resident and the staff member to
enjoy a visit rather than simply perform a
procedure.
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(B) The facility shall make available and
implement self-care, productive and leisure
activity programs which maximize and
encourage the resident’s optimal functional
ability for residents. The facility shall provide
person-centered activities appropriate to the
resident’s individual needs, preferences,
background and culture. Individual or group
activity programs may consist of the
following:
1.
2.
3.
4.
5.
Gross motor activities, such as exercise,
dancing, gardening, cooking and other routine
tasks;
Self-care activities, such as dressing, grooming
and personal hygiene.
Social and leisure activities such as games,
music and reminiscing.
Sensory enhancement activities, such as
auditory, olfactory, visual and tactile
stimulation.
Outdoor activities, such as walking and field
trips.
7.
Other social, leisure or therapeutic activities
that encourage mental and physical
stimulation or enhance the resident’s wellbeing.
(C) Staff shall inform residents in advance of
any organized group activity including the time
and place of the activity.
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19 CSR 30-86.043(57) Residents shall be
encouraged to be active and to participate in
activities. In a facility licensed for more than
twelve (12) residents, a method for informing
the residents in advance of what activities are
available, where they will be held and at what
times they will be held shall be developed,
maintained and used.
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The changes to the interpretive guidance for
F248/F249 reflects a shift in perspective to
interpreting activities as they pertain to every
facet of care that an individual who comes to
skilled nursing care receives.
The stated intent of F248 “facility is required
to identify diverse interests of each resident
and develop a program of care to meet those
needs and interests.
The mere development of a program is not
sufficient for compliance.”
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The facility must promote care for residents
in a manner and in an environment that
maintains or enhances each resident’s dignity
and respect in full recognition of his or her
individuality.
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“Dignity” means that in their interactions with
resident, staff carries out activities that assist
the resident to maintain and enhance his/her
self esteem and self-worth with grooming,
dressing, and assisting residents to attend
activities of their own choosing.
Respecting private space and property (TV
and Radio on to resident’s preference).
Conversing with resident during cares.
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During group activities does the staff focus their
attention on the group of residents or talk to
other staff members instead?
Are residents restricted from using common
areas open to the public such as the lobby or
common area restrooms?
Do staff members respond to residents with a
cognitive impairment in a dignified manner, such
as not contradicting what residents are saying,
and addressing what residents are trying to
express (the agenda) behind their behavior.
The resident has the right to—
(1) Choose activities, schedules and health care
consistent with his or her interests, assessments
and plans of care;
 Both formal and self-directed activities
 Choice over their schedule—bedtime, bathing,
therapy, attending activities, meals, etc….
 Does the staff provide assistance as needed to
the resident to be able to engage in their
preferred activities on a routine basis?
 Does the facility assess to determine resident’s
preferences regarding routine?
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(1) A resident has the right to organize and
participate in resident groups in the facility;
(2) A resident’s family has the right to meet in
the facility with the families of other residents
in the facility;
(3) The facility must provide a resident or family
group, if one exists, with private space;
(4) Staff or visitors may attend meetings at the
group’s invitation;
(5) The facility must provide a designated staff
person responsible for providing assistance and
responding to written requests that result from
group meetings.
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When a resident or family group exists, the
facility must listen to the views and act upon
the grievances and recommendations of
residents and families concerning proposed
policy and operational decisions affecting
resident care and life in the facility.
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A resident’s or family group is defined as a group
that meets regularly to:
Discuss and offer suggestions about facility
policies and procedures affecting residents’ care,
treatment and quality of life;
Support each other;
Plan resident and family activities
Participate in educational activities; or
For any other purpose.
If no resident or family group exits, has the
facility tried to impede the formation of such a
group?
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A resident has the right to participate in
social, religious, and community activities
that do not interfere with the rights of other
residents in the facility. (both inside and
outside of the facility)
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A resident has a right to—
Reside and receive services in the facility with
reasonable accommodations of individual
needs and preferences, except when the
health or safety of the individual or other
residents would be endangered.
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Reasonable accommodations means the
facility’s effort to individualize the resident’s
physical environment, including bedroom,
bathroom and facility’s common living areas.
(Furniture, fixtures, task lighting to allow for
resident’s chosen activities, and electronics)
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Staff should interact with the resident in a way that takes
into account the physical limitations of the resident,
assures communication, and maintains respect.
For example: Getting down to eye level with a resident
who is sitting.
Speaking so a resident with limited hearing who reads lips
can see their mouth when they speak.
Utilizing a hearing amplification device such as a pockettalker. Move resident from a noisy area so they can
communicate.
Residents who use glasses, hearing aids or similar devices
should have them in use, clean, and functional.
Call light within reach.
Adaptive equipment to participate in resident-preferred
activities.
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The facility must provide for an ongoing
program of activities designed to meet, in
accordance with the comprehensive
assessment, the interests and the physical,
mental, and psychosocial well-being of each
resident.
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The intent of this requirement is that:
The facility identifies each resident’s interests
and needs; and
The facility involves the resident in an
ongoing program of activities that is
designed to appeal to his or her interests and
to enhance the resident’s highest practicable
level of physical, mental and psychosocial
well-being.
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“Activities” refer to any endeavor, other than
routine ADL’s, in which a resident participates
that is intended to enhance his/her sense of
well-being and to promote or enhance physical,
cognitive, and emotional health. These include,
but are not limited to, activities that promote
self-esteem, pleasure, comfort, education,
creativity, success and independence.
(ADL-related activities, such as
manicures/pedicures, hair styling and makeovers
may be considered part of the activities
program.)
“One-to-One Programming” refers to
programming provided to residents who will
not, or cannot, effectively plan their own activity
pursuits, or residents needing specialized or
extended programs to enhance their overall
daily routine and activity pursuit needs.
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“Person Appropriate” refers to the idea that
each resident has a personal identity and
history that involves more than just their
medical illnesses or functional impairments.
Activities should be relevant to the specific
needs, interests, culture, background, etc. of
the individual for whom they are developed.
“Program of Activities” includes a combination
of large and small group, one-to-one, and selfdirected activities; and a system that supports
the development, implementation, and
evaluation of the activities provided to the
resident’s in the facility.
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The ongoing activity program should be
based upon the resident’s individual needs
and enhance their self-esteem and dignity.
The activity program should match the skills,
abilities, needs and preferences of each
resident with the demands of the activity.
The resident’s characteristics should also
match the characteristics of the physical,
social and cultural environments of the
activity program.
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Daily life and involvement in activities should
be meaningful.
Activities are meaningful when they reflect a
person’s interests and lifestyle.
Bring enjoyment to that person.
Help the person to feel useful.
Provide a sense of belonging.
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Activities are relevant and valuable to our
resident’s quality of life.
Quality of Life=Dignity
Dignity = Independence and Positive SelfImage
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Choice of Activities
Activities that amount to something
a. Activities that produce or teach something
b. Using skills from resident’s former work
c. Religious activities
d. Activities that contribute to the nursing
home
e. Activities that require thinking
f. Gender specific
g. Allow for socializing with visitors and
participating in community events.
h. Physically active activities
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Complete an Activity Assessment to identify the
resident’s interests, preferences and abilities.
Use resident and family interviews to obtain
information.
Include the resident’s lifelong interest,
spirituality, life roles, goals, strengths, needs,
activity pursuit patterns and preferences.
Identify any issues, concerns, problems or needs
affecting the resident’s involvement/engagement
in activities. What adaptations do they need?
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Activity Goals should be measurable objectives
that focus on desired outcomes.
For example:
a. Engagement in an activity that matches the
resident’s ability.
b. Maintain attention to the activity for a
specified period of time.
c. Express satisfaction with the activity verbally
or non-verbally
d. Not merely a goal of attending a certain
number of activities per week.
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The Care plan should also identify who is going to
carry out the approaches.
Examples:
a. Notify resident of preferred activities.
b. Transport residents who need assistance to and
from activities.
c. Provide needed functional assistance (such as
toileting and eating assistance)
d. Provide needed supplies or adaptations, such as
obtaining and returning audio books, setting up
adaptive equipment, etc.
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A continuation of life roles, consistent with
resident preferences and functional capacity
(e.g., to continue work or hobbies such as
cooking, table setting, repairing small
appliances)
Encouraging and supporting the development of
new interests, hobbies, and skills (e.g. training
on using the internet)
Connecting with the community, such as places
of worship, veteran’s groups, volunteer groups,
support groups, wellness groups, athletic or
educational connections.
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Activities can occur at any time.
Are not limited to formal activities being
provided by the Activity staff.
Includes activities provided by other facility
staff, volunteers, visitors, residents and
family members.
All relevant departments should collaborate
to develop and implement an individualized
activities program for each resident.
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The facility may need to consider accommodations in
schedules, supplies and timing in order to optimize a
resident’s ability to participate in an activity of choice.
Examples:
a. Alter a therapy or shower schedule to make it
possible for a resident to attend a desired activity.
b. Assist residents to be ready to attend an activity
(dressing, toileting, transportation)
c. Provide supplies (e.g., books/magazines, music,
crafts, sorting materials) for activities and
assistance when needed, for residents’ use (e.g.,
during weekends, nights, holidays, evenings, or
when the activities staff are unavailable)
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Time the administration of medications to
avoid interfering with the resident’s ability to
participate or to remain at a scheduled
activity. (diuretics, incontinence, pain)
Modify the administration time of pain
medication to allow the medication to take
effect prior to an activity the resident enjoys.
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Adapt for visual impairments:
a. Provide higher levels of lighting without glare.
b. Provide magnifying glasses
c. Light-filtering lenses
d. Telescopic glasses
e. Use of “clock method” to describe where items are
located.
f. Describe sizes, shapes, colors.
g. Provide large print items including playing cards,
newsprint, books
h. Audio books
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Adapt for hearing impairments
a. Involve in small group activities
b. Placement of resident near speaker/activity
leader
c. Use amplifiers or headphones.
d. Decrease background noise
e. Use written instructions
f. Use of gestures or sign language to enhance
verbal communication.
g. Adapted TV (closed captioning, magnified
screen, earphones)
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Adapt for physical limitations
a. Use adaptive equipment
b. Ensure proper seating and
positioning
c. Adjust placement of supplies and materials to
enhance
1. visual interaction and to compensate for loss
of visual field.
2. upper extremity function and range of motion
(reach)
3. Hand dexterity (e.g., adapt size of items such
as larger handles for cooking and
woodworking equipment, built-up paintbrush
handles, large needles for crocheting)
4. The ability to manipulate an item based upon
the item’s weight, such as lighter weight
for residents with muscle weakness.
d. For
the resident who has the use of only one
hand: holders for kitchen items,
magazines/books, playing cards;
items (e.g., art work, bingo card, nail file)
taped to the table; c-clamp or suction vise to
hold wood for sanding.
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Task segmentation and simplification
Programs using retained long-term memory,
rather than short term memory.
Length of activities based on attention span.
Settings that recreate past experiences or
increase/decrease stimulation
Smaller groups without interruption
One-to-one activities
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The length, duration and content of specific
one-to-one activities are determined by the
specific needs of the individual resident.
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Sensory Stimulation or Cognitive Stimulation
a. Stimulation of the five senses (vision, hearing,
touch, taste and smell)
b. Reminiscing
c. Validation Therapy-validate the feeling, not
challenge the facts. Reminisce from that point.
d. Special stimulus rooms like a Snoozylyn Room or
sensory stimulation equipment
e. Music
f. Aromatherapy
g. Stimulate the sense of touch with varying textures.
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Social engagement
a. Directed conversation with staff or
volunteer
b. Initiate a resident to resident conversation
c. Coffee and chat
d. Pleasure walk
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Spiritual support and nurturing
a. Daily devotion
b. Bible reading
c. Prayer with or for resident per religious
requests/desires.
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Creative or Task Oriented Activities
a. Music
b. Pet visits
c. Letter writing
d. Word Puzzles
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Support of self-directed activity.
a. Providing supplies such as reading
material, craft supplies, setting up talking
books, etc.
Language Barriers
Provide translation tools or a translator.
Offer publications and/or audio video materials
in the resident’s language.
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Offer spiritual support
Relaxation programs
Music
Massage
Aromatherapy
Pet Visits
Appropriate Touch
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For residents who are unable to leave their room or
prefer to remain in their room:
a. Provide in-room visits by staff or volunteers with
similar interests/hobbies
b. Sensory Stimulation activities such as
appropriate touch, massage or aromatherapy
c. Ensure access to art/craft materials
d. Offer cards, games, reading materials
e. Provide access to technology of interest
(computer, DVD, hand held video games)
f. Assist with preferred radio programs/stations
g. Offer audio books
h. Offer visits from spiritual counselors
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Ensure activities are available during awake time.
a. Nursing staff reads with resident
b. Dietary makes finger foods/snacks available
c. CNA completes an activity with resident like
working a puzzle, etc.
d. Maintenance staff takes resident on night
rounds.
e. Individual or self-directed activity supplies
are available and accessible.
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Develop ways to make your new residents
feel welcome and are orientated to facility
and routine.
a. Welcome Committee
b. Welcome packet
c. Gift bag
d. Who to contact in the facility for
needs/questions.
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Short-stay residents may choose to not engage
in the facility activities program. Offer “a la carte
activities” that can be used when the resident
desires.
Examples may include books, magazines, cards,
word puzzles, newspapers, CDs, movies, and
handheld games.
Offer engagement in small group activities such
as dominoes, bridge, poker, movies, travelogues.
Offer individual activities designed to match the
goals of therapy, such as enhancing fine motor
skills or cognition.
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Offer age-appropriate activities.
a. Individual and group music offerings
that fit the resident’s taste and era.
b. Magazines, books and movies that fit
the resident’s interests.
c. Computer and internet access
d. Contemporary group activities such as
video games, playing musical
instruments, card and board games
and sports.
e. Outings
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Accommodate and celebrate your resident’s
diverse ethnic or cultural backgrounds.
Plan special events that include meals,
decorations, celebrations, or music from their
culture.
Arrange for visits from spiritual leaders and other
individuals of the same ethnic background.
Printed materials (newspaper and magazines)
about the resident’s culture.
Provide opportunities for the resident and family
to share information about their culture with
other residents, families and staff.
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Emphasis is on Person Centered Care, especially for residents
with dementia.
If a resident has dementia, the facility must:
~ Do everything possible to manage behaviors without
medications.
~ Continual monitoring and documentation of the
resident’s behaviors, medical conditions, and social
situations.
~ Document all of the non-medication interventions tried
and how they worked.
~ Document /describe how the behavior seriously impairs
the resident’s quality of life.
--Cynthia Hadfield, Pharm.D.
Director of Pharmacy, Retail /Employee / LTC Pharmacies
Lead Clinical Pharmacist, CMH Foundation
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The facility staff need to provide activitiesrelated interventions to try to minimize
distressed behaviors.
Care Plan these intervention.
Document resident’s response to the
interventions.
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Provide a space for the resident to walk safely.
Provide environmental cues that encourage
physical exercise, decrease exit behavior and
reduces extraneous stimulation.
For example: Provide seating areas spaced along
a walking path or garden.
Have an area that a resident may manipulate
items such as a rummaging dresser or activity
box filled with items to touch, fold, sort, stack,
put on, etc.
Provide a room with a calming atmosphere with
music, lights, rocking chair, etc.
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A Snoezelen Room is a therapeutic environment
created for the express purpose of delivering
high levels of stimuli to patients with dementia.
A room that displays optical illusions with
combined lighting effects, aromas, colors,
textures and sounds to stimulate a person’s
olfactory, auditory and gustatory systems.
Sensory therapy has proven effective in calming
aggressive behavior and improving mood.
https://www.youtube.com/watch?v=ZbiVadI7VGk
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The use of concentrated plant extracts for
curative purposes, provides soothing sensory
stimulation that may relieve agitation and
boredom in elderly adults with dementia.
Aromatherapy with lavender, rosemary,
chamomile and other essential oils may
temporarily relieve anxiety and emotional
disturbances in elderly adults with dementia.
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Symptoms such as wandering, aggression
and sleep loss increase the risk of injury in
frail older adults who suffer from Alzheimer's
disease or other neurological conditions that
affect memory and cognition. Restoring a
sense of calm may increase safety, improve
quality of life and reduce stress on caregivers.
More research is required to confirm the
benefits of aromatherapy for elderly adults.
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As part of a comprehensive approach to
medical treatment, aromatic essential oils
may be inhaled or massaged into the skin to
ease agitation and improve cognitive function
in seniors.
If you're planning care for an elderly person
with dementia, consult a medical professional
about the potential benefits and side effects
of aromatherapy. Clinical evidence has not
confirmed that aromatherapy is an effective
treatment for dementia.
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Validate the resident’s feelings and words.
Validation is a method of communicating with
and helping disoriented very old people. It is a
practical way of working that helps reduce stress,
enhance dignity and increase happiness.
Validation is built on an empathetic attitude and
a holistic view of individuals. When one can "step
into the shoes" of another human being and "see
through their eyes," one can step into the world
of disoriented very old people and understand
the meaning of their sometimes bizarre behavior.
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Validation theory explains that many very old disoriented
people, who are often diagnosed as having Alzheimer
type dementia, are in the final stage of life, trying to
resolve unfinished issues in order to die in peace.
Their final struggle is important and we, as caregivers,
can help them. Using Validation techniques we offer
disoriented elderly an opportunity to express what they
wish to express whether it is verbal or non-verbal
communication.
Validation practitioners are caring,
non-judgmental and open to the feelings that are
expressed.
When disoriented elderly can express the things
that have often been suppressed for many years, the
intensity of the feelings lessen, people communicate
more and are less likely to withdraw into further stages of
disorientation.
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Validation is a theory that very old people
struggle to resolve unfinished life issues before
death. Their behavior is age-specific. Their
movements reflect human needs. Validation is a
way of classifying their behaviors into four
progressive stages:
◦ Malorientation- Expressing past conflicts in disguised
forms.
◦ Time confusion- No longer holding onto reality;
retreating inward.
◦ Repetitive motion- Movements replace words and are
used to work through unresolved conflicts.
◦ Vegetation- Shuts out world completely and gives up
trying to resolve living .
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https://www.youtube.com/watch?v=ESqfW_kyZq8
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Provide one-to-one visits with the resident.
Look at photo albums or familiar pictures.
Read to the resident.
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For the resident who engages in name-calling,
hitting, kicking, yelling, biting, sexual behavior or
compulsive behavior:
Provide a calm, non-rushed environment.
Provide a structured routine with familiar activities
such as folding, sorting or matching.
Use one-to-one or small group activities that provide
comfort, such as music, walking quietly with
someone, eating a favorite snack, looking at familiar
pictures.
Engage in exercise and movement activities.
Redirect/exchange self-stimulatory activity for a
more socially-appropriate activity that uses the
hands, if in a public space.
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Residents who disrupt group activities with behaviors such as
talking loudly and being demanding, or the resident who has
catastrophic reactions such as uncontrolled crying or anger, or
the resident who is sensitive to too much stimulation:
Offer activities that help the resident feel successful. Break
down activities into simple steps.
Involve in small groups or one-to-one activities that are short
and repetitive.
Stop the activity if the resident becomes overwhelmed.
Reduce excessive noise such as from the TV.
Involve in familiar occupation-related activities. (Sorting
supplies, helping deliver resident mail, snacks or juice, etc.)
Involve in physical activities such as walking, exercise or dance.
Play games or engage in projects that require strategy, planning
and concentration such as model building.
Engage in creative programming such as music, art or dance.
Offer physically resistive activities such as kneading clay,
sanding, scrubbing, stretch bands, or lifting weights.
Offer slow exercises such as slow tapping, clapping or
drumming; rocking or swinging motions.
Don’t forget to try a rocking chair.
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Use normalizing activities such as stacking canned food
onto shelves, folding laundry; offering sorting activities
(sorting socks, ties, buttons, etc.)
Involve in organizing tasks such as putting activity
supplies away.
Provide rummage areas in plain sight, such as a dresser
or cart.
Use non-entry cues, such as “Do not disturb” signs or
removable sashes at the doors of residents’ rooms.
Provide locks to secure other resident’s belongings if
requested.
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Provide activities just before or after meal time in the dining
room (so they are out of their room)
Provide in-room volunteer visits, music or videos of choice.
Encourage volunteer-type work that could begin in the room and
needs to be completed outside of the room.
Ask the resident to host a small group activity in their room.
Engage in failure-free activities such as a simple craft or an
activity with a friend.
Invite to special events with a friend or family.
Encourage resident to play a helping roll and assist another
resident.
Engage in activities that give the resident a sense of value such
as intergenerational activities.
Invite resident to participate on facility committees.
Invite the resident outdoors.
Involve in gross motor exercises to increase energy and uplift
mood, such as aerobics or light weight training.
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Offer opportunities for leadership
Involve in social programs
Small group activities
Service projects
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For the resident who lacks awareness of personal
safety, such as putting foreign objects in his/her
mouth or who is self-destructive and tries to harm
self by cutting or hitting self, head banging, or
causing other injuries to self:
Observe closely during activities.
Take precautions with materials.
Involve in smaller group or one-to-one activities that
use the hands such as folding, putting together PVC
tubing)
Engage in activities that are emotionally soothing,
such as listening to music or talking about personal
strengths and skills, followed by participation in
related activities.
Focus attention on physical activities such as
exercise.
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When delusional and hallucinatory behavior
is stressful to the resident:
Focus the resident on activities that decrease
stress and increase awareness of actual
surroundings such as familiar activities and
physical activities.
Offer verbal reassurance, especially in terms
of keeping the resident safe.
Acknowledge that the resident’s experience
is real to him/her.
The outcome for the resident, the decrease
or elimination of the behavior, either
validates the activity intervention or suggest
the need for a new approach.
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A friend is someone who knows the song of
your heart and can sing it back you when you
have forgotten the words.
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Moments of Joy are those little things that
anyone can do to spark a memory, create a
moment that makes you smile, leaving you with a
happy feeling.
What is that person’s greatness? What has
brought that person great joy throughout their
lives? Use these key topics to bring joy.
All staff members can help make a resident’s day
special, happy and comfortable.
Feelings linger on……what was said was really
not the point.
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A person with Alzheimer’s will lose their shortterm memory. Our goal is help them grasp
memories from their long-term memory and
create moments of joy.
When you chat with them, don’t ask about what
they had to eat for breakfast. Target the longterm memory and ask what they like to eat for
breakfast….pancakes, biscuits and gravy?
Instead of asking if their son came to visit, say
something about their son….like “Your son is a
wonderful kid, he looks a lot like you.” Spark
that memory for them, leave them with a happy
feeling.
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Because of their short-term memory loss they
will repeat themselves over and over. Key in
on the topics that elicit a happy memory for
them and let them tell that story 100 times.
When they are feeling sad, bring up that topic
to help redirect them to that happy memory.
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There is no reasoning with a person who has
Alzheimer’s and you will not be able to make
them live your reality.
Provide reassurance to their fears, their reality.
This is the only disease where you can make
mistakes as a caregiver all day long, because in
five minutes they come around the corner and
ask the same question. Keep changing your
answer until you find the one that works.
Once you find the answer, tell everybody, so
moments of joy can be created all day long.
Stop correcting them.
 Use distraction and redirection.
 “I’ve been looking for you! Let’s go get some
coffee or cookies.”
 Before you correct them, ask yourself 3
questions.
1. Does it physically hurt you (the staff member) in
any way for this behavior to occur.
2. Does it physically hurt any of the other people
living here?
3. Does it physically hurt the person with dementia?
If no one is getting hurt, let them do what they
want to do.
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If you do need to take something away,
replace it with something else.
Leaving the person with nothing leaves a
feeling of emptiness and loss.
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Find out from family members what the
dementia person’s favorites are. Get specific
information so you can focus on these things
to create moments of joy.
Favorite: snack, drink, nickname,
temperature, chair, color, hair style, sweater,
outfit, outings, music, stories, hobbies, best
friends, travels, etc….
Find at least 20 things. Share the favorites
list with staff and visitors.
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As Alzheimer’s disease progresses, the resident gets
younger in their mind. Ask them how old they are to help
you determine the best way to relate to them. Or observe
what they are talking about to help you figure out their
age. For example, if they are looking for their children but
do not recognize them, they are probably in their younger
adult years. If they are looking for their parents, they are
probably in adolescence.
Once you know what age, figure out what was significant
in their life at that time and use those details to create
moments of joy.
“Everything is in the process of being forgotten. But who we
are—who we have been in mood, in personality, in
character—persists much longer.” --David Dodson Gray
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In the middle stages of Alzheimer’s, their
developmental level is 8 years old and regresses to 5
years old.
In the late stages of Alzheimer’s, their developmental
level is age 3 or younger.
As the disease progresses, their development
regresses.
An adult with dementia also loses inhibitions and say
exactly what they are thinking. Their filter is gone.
“No” becomes a common word for them as their
developmental level regresses.
A person with dementia needs structure and routine.
Don’t forget to have a time for rest.
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A person with Dementia may not recognize
their family members, but they have not
forgotten them.
Help reassure the family they have not been
forgotten.
Use pictures of the family during their
younger years to help spark a memory for the
resident.
A dementia person will recognize a tone of
voice far into the disease, but you have to get
out of their sight in order for this to happen.
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Be the sunshine in the room. Your mood affects their mood.
Radiate warmth, patience, smile.
Be like a duck……relaxed, floating on the pond in the sun.
Care free. But underneath we are busy paddling non-stop
trying to get all of our tasks completed. Don’t let them see
the busy paddling.
Talk about everyday things…..spark a memory.
Tell a joke.
Help the resident engage in something of interest to them.
Use touch and a calm tone of voice to reassure.
Keep changing the way we respond to them until we find a
way to create a moment of joy for them.
Each day is a new day, we can keep trying to find what will
touch them.
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Talk to them on eye level.
Make eye contact.
Compliment them.
Say something to try to elicit a memory from
them. Help them to relive one of their own
simple pleasures.
Don’t ask “How are you today?” Say
something like, “I love your ___________ today.
Simplify the task/activity until they can do it.
Gives them a sense of purpose to do as much
for themselves as possible.
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90% of what a dementia person understands
is body language, not the words that come
out of your mouth.
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Be aware of your body language and send a positive
message.
Try a calm, gentle, matter-of fact approach.
Reduce background noise.
Position yourself directly in front of him, at his eye level,
and make sure you have his attention before you start to
speak.
Touching a person on the shoulder or holding her hand
may help her focus on what you are trying to
communicate.
Show a person what you are wanting him to do by
demonstrating.
Praise non-verbally through hugs, a caring smile, or a pat
on the back.
Walk away and try again later with a different approach.
o
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Speak slowly in a low-pitched voice
Enunciate your words
Begin your conversation socially
Use short, familiar words and simple sentences
Talk in a warm, easy-going, pleasant manner
Ask simple questions that require a choice of a yes/no
answer.
Listen carefully
Give positive instructions and avoid “don’t…can’t” or negative
commands.
Avoid questions that require short-term memory
e.g. :Did your daughter come to see you today?”
Communicate using the person’s long-term memory: “I hear
you have a wonderful daughter.”
Give simple instructions for one task at a time (The simple
task of brushing teeth contains 11 steps.)
Keep talking to the person with dementia, even if he cannot
talk back.
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The person with dementia may not
understand your words, or be able to
articulate their thoughts into words, but they
do know how they feel right now. Respond to
their emotion not their words.
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Listen actively and carefully
Focus on a word or phrase that makes
sense
Respond to the emotional tone of the
statement, not the words
Stay calm and be patient
Ask family members about possible
meanings for words, names, or phrases
Respond as though you understand
Try a hug and change the subject
Simply say Wow!
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Don’t argue with the person
Don’t order the person around
Don’t tell the person what he or she can’t do
Don’t be condescending
Don’t talk about people in front of them.
People with dementia can hear, think, and feel
emotions! Do not talk over, through, or about
them as if they are not there.
Avoid whispering because it arouses suspicion.
Yelling into a person’s ear who cannot hear very
well will only upset or frighten them.
Get their attention before you start speaking to
them.
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Compliment, Compliment, Compliment!
Remind them who they are and give them
their memories back.
For example:
Close your eyes ….and go back…..way back:
Hide and seek at dusk.
Sitting on the porch.
Hot bread and butter.
Penny candy in a brown bag.
Hopscotch, kickball and Annie over!
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Cowboys and Indians.
When around the corner seemed far away.
And going downtown seemed like going
somewhere.
Being tickled to death.
Playing slingshot and Red Rover.
Climbing trees.
Building forts.
Running till you’re out of breath.
Laughing so hard it hurts.
Licking the beaters when your mom made a cake.
Being tired of playing
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I will be here all day if you need anything.
Don’t worry. I’ll take care of it.
You are pretty important around here.
If you need anything, just let me know.
I do silly things like that, too.
Between the two of us, we will be OK.
You are a pretty special person.
Wow, you are so smart!
Thank you, I couldn’t have done it without you!
That’s a good idea, I will have to try that!
You always look out for me.
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Dementia resident may repeat, repeat, repeat
themselves.
Caregivers need to be patient, patient ,
patient.
Distract rather than react.
Use short, simple responses: “That’s
interesting. You’re right. OK. I don’t know.
Listen without judgment to give dignity.
Affirm their conversation whether you agree or
even understand what they are saying.
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www.enhancedmoments.com
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https://www.youtube.com/watch?v=NKDXuC
E7LeQ
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Resident activities are everyone’s
responsibility.
Help your staff understand the significance in
meeting the resident’s social and emotional
needs, in addition to their physical and
healthcare needs.
Engaged residents are happier, less needy
and are more fun to take care of and interact
with.
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CNAs provide assistance to help the resident
participate in desired group and individual activities
by:
Ensuring the resident is out of bed, dressed and
ready to participate in chosen group activities and in
providing transportation if needed.
Provide any needed ADL assistance to the resident
while he/she is participating in group activities.
Help the resident to participate in individual activities
such as set up equipment/supplies, positioning
assistance, provide enough lighting and space for the
activity.
Help provide care planned activities for the resident
at times when activities staff are not available.
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Ensure that the CNAs assist the resident in
participating in activities of choice.
Coordinate schedules for ADLs, medications and
therapies to maximize the resident’s ability to
participate.
Make nursing staff available to assist with
activities in and out of the facility.
Try to identify and address the reason a resident
is refusing to participate in activities.
Coordinate the resident’s activities participation
when activities staff are not available to provide
care planned activities.
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Help facilitate resident participation in
desired activities.
Address the resident’s psychosocial needs
that impact on the resident’s ability to
participate in desired activities.
Helps obtain equipment and/or supplies that
the resident needs in order to participate in
desired activities.
Helps the resident access his/her funds in
order to participate in desired activities that
require money.
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Be aware of scheduled activities and talk it up!
Encourage residents to attend activities.
Offer to assist them to the activity.
Engage in conversation, singing or story telling
while you are in there completing your tasks.
In their room, leave them with something to do.
Would you like to watch TV, listen to the radio or
talking books, look out the window, sit in the day
area, work on an individual activity, hold their
stuffed animal or doll, look at a magazine, work
on a puzzle, get on the computer, etc….
Compliment the resident.
Create a moment of joy!
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Schedule activities that involve your staff.
These are easy to coordinate with National
Nursing Home Week, holidays, special events.
Staff are encouraged to participate, dress up, be
a part of the fun!
A little competition can be lots of fun and helps
with team building.
Seeing the staff get involved also helps motivate
your residents to get more involved. Gives
everyone a chance to connect on another level,
laugh and have fun!
Compliment staff for participation and
engagement.
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Easter Parade and Easter Egg Hunt
Pet Parade
Trick-or-Treaters/Costume Contest
Pumpkin Decorating Contest
Golden Age Games
Door Decorating Contest
Theme Days/Dress up days
Scavenger Hunt
Celebrate National _____________Days
Craft fair
What are your employee’s talents? Would they be willing
to share their talent?
What groups, church, clubs, teams are your employees in
or their family in? Would they be willing to come to the
facility?
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What can you do to reward your staff for going
the “extra mile” for your residents?
Offer a treat to the staff who assist a resident to
the activity.
Coordinate an employee appreciation from the
residents. ( Thank you card, treat bags, hearts
and hugs, etc.)
HEROES reward. When employees receive thank
you notes from residents, families, visitors, peers
they can earn points. When they reach 25 points,
they receive a $25 check.
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We all need to feel like we make a difference.
Rich Bluni says, "Engagement is actually a
critical work skill wearing a fluffy disguise. It
is the sense of feeling tuned into, a part of, a
contributor to our calling and our mission."
Acknowledge your staff’s important role at
your facility. Make them feel like each person
is a key player and appreciated.
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Recognition focuses primarily on
performance or the achievement of certain
goals.
Appreciation focuses on the value of the
individual.
Take time to do both!
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Thank you notes from supervisor, peers,
administration.
Supervisors and Administration can mail thank you
notes to their home, so their family can see their
accomplishments too.
Recognize Employee Birthdays.
Recognize their anniversary with your facility.
Team Build with Pot Luck luncheons.
Coordinate Employee Secret Santas/Secret Pals.
Recognize Departments during National Appreciation
Days/Weeks.
Employee Appreciation during the Holidays with a
meal or party.
Resident Welcoming Committee for new employees.
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Incorporate Personal Praise & Recognition
Written Praise & Recognition
Electronic Praise & Recognition
Public Praise & Recognition
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Match the Reward to the Person
Match the Reward to the Achievement
Be timely and Specific
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When your employee’s groups come to the
facility, try to get a picture in the paper or at
least your newsletter and Facebook page.
Recognize certifications, graduations,
conference completions, etc….in your
newsletters, on your bulletin boards, on
Facebook, in the newspaper.
Recognize your employee’s children, with
permission, whenever you can. Also shows
community support.
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The magic ratio of 5 positive interactions for
every 1 negative interaction has been proven
to improve productivity and satisfaction in
the work place.
--How Full Is Your Bucket? By Tom Rath and Donald Clifton, Ph.D.
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Everyone has an invisible bucket. We are at
our best when our buckets are overflowing—
and at our worst when they are empty.
Everyone also has an invisible dipper. In each
interaction, we can use our dipper either to
fill or to dip from other’s buckets.
Whenever we choose to fill other’s buckets,
we in turn fill our own.
1.
2.
3.
4.
5.
6.
7.
By what name do you like to be called?
What are your “hot buttons”—hobbies or interests you like
to talk about a lot?
What increases your positive emotion or “fills your bucket”
the most?
From whom do you like to receive recognition and praise?
What type of recognition or praise do you like best? Do
you like public, private, written, verbal, or other kids of
recognition?
What form of recognition motivates you the most? Do you
like gift certificates, a title for winning a competition, a
meaningful note or e-mail, or something else?
What is the greatest recognition you have ever received?
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Increases their individual productivity
Increases engagement among their
colleagues
More likely to stay with their organization
Receives higher loyalty and satisfaction
scores from customers
Better safety records and fewer accidents on
the job
How Full Is Your Bucket?
Positive Strategies for Work and Life
by Tom Rath and Donald Clifton, Ph.D.
The spirit we have, not the work we do, is what makes
us important to people around us.
--Sister Joan Chisttister
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The Long Term Care Survey Manual Guidance
to Surveyors Section V
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