Background <p>Older adults living in institutional settings often face barriers to maintaining engagement in meaningful activities, which may compromise occupational balance, autonomy and overall well-being. Although a wide range of activity programmes is typically offered, the factors influencing meaningful engagement and occupational balance in these environments remain poorly understood.</p> Methods <p>An observational one-year cohort study was conducted across four nursing homes and day centres in Andalusia (Spain). A total of 144 institutionalised older adults were assessed at baseline and at 12-month follow-up. Engagement in meaningful activities was measured using the Engagement in Meaningful Activities Survey (EMAS). Occupational balance was assessed using the Spanish version of the Occupational Balance Questionnaire (OBQ-E). Functional status was assessed with the Functional Independence Measure (FIM) with frailty being assessed through the Fried’s criteria. Participation in daily living, cognitive, leisure, physical and sensory and community activities was recorded. Paired t-tests, simple linear regressions and hierarchical linear regression models were used to examine change over time and predictors of the two main outcomes.</p> Results <p>Functional status, frailty and cognitive engagement appear to be key determinants of meaningful participation and occupational balance in. The predominance of highly structured leisure activities within current institutional programmes may limit opportunities for meaningful engagement. These findings highlight the potential value of co-designed, person-centred activity programmes better aligned with interests, values, and functional abilities of the institutionalised older adults to support more meaningful ageing in institutional settings.</p> Conclusions <p>These findings underscore the need to review the type and range of activities offered in institutional settings, reducing time devoted to highly structured leisure activities and promoting more enriching experiences. To do so, experience-based co-design approaches involving institutionalised older adults and professionals in these settings are essential to develop person-centred programmes to enhance engagement in meaningful activities and occupational balance. Future research should include controlled designs and mixed methods to better capture the complex interplay between health status, contextual factors and activity engagement in institutionalised settings.</p>