Activities Program Directed by Unqualified Staff
Summary
The facility failed to ensure the activities program was directed by a qualified professional. Review of the activity calendars for December 2025 and January 2026 showed the activities were repetitive and did not include a variety of activities. The deficiency was identified through staff interview and review of personnel files, which showed Activity Director #102 was not a qualified professional as defined in the report. Her file indicated she was not a certified therapeutic recreation specialist or activities professional, was not eligible for certification by a recognized accrediting body, did not have two years of experience in a social or recreational program within the last 5 years with one year full-time in therapeutic activities, was not a qualified OT or OTA, and had not completed a State-approved training course. Interviews confirmed the facility did not have a certified activity staff member until Activity Aide #100 was hired on 10/07/25. Activity Director #102 stated she had been the Activity Director for about three years and that she and another activity aide worked with the non-memory care portion of the building. Regional Director of Operations #210 and the Interim Administrator stated they believed the facility did not need a certified activity aide and believed the Activity Director met the experience requirement. However, further review of the Activity Director's personnel file and resume showed she had only nine months of activity experience at a previous facility from February 2022 to November 2022, and no additional activity-related experience was identified.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility allowed its activities program to be directed by an individual who did not meet the required qualifications for an activities director. Personnel records showed the activities director was hired without the necessary credentials, and this was confirmed by the Regional Director of Clinical Operations. This deficiency had the potential to affect nearly all residents who participated in facility activities, given the overall census and the small number of residents identified as non-participants.
The facility did not ensure its Activities Program was overseen by a qualified Activities Director, as the staff member in the role lacked required certification or training and was originally hired for social services. Resident Council meetings were facilitated by an Activities Aid, and management was not kept informed of resident concerns from these meetings.
The facility assigned an unqualified staff member to direct the activities program, with no evidence of required certification, licensure, or experience in her personnel file. Interviews with the staff member and facility leadership confirmed she did not meet the qualifications for the role, and she only began a certification course after assuming the position.
The facility failed to ensure the Activities Director met required qualifications, as the individual lacked necessary experience and declined to complete state-approved training. Activities aides reported insufficient training, poor communication, and lack of support, resulting in disorganization and unmet needs within the activities program.
The facility assigned an Activities Director who lacked required certification and experience, and whose personnel file did not include a signed job description. This was confirmed by interviews with the Activities Director, HR, and the Administrator, all of whom acknowledged the absence of necessary qualifications. The deficiency had the potential to impact all residents, as the Activities Director was solely responsible for the activities program.
The facility failed to ensure its activities program was led by a qualified professional, as the current Activity Director lacked required certification and prior experience, and was only enrolled in a certification program after surveyor inquiry. Oversight was provided by a DCS/RN who also lacked activity director certification, potentially affecting all residents.
Unqualified Staff Member Directing Activities Program
Penalty
Summary
The facility failed to ensure its activities program was directed by a qualified professional, as required. Review of the personnel record for the Activities Director showed a hire date of 04/02/26 and further revealed that this individual did not meet the qualifications required to serve as an activity director in the facility. An interview with the Regional Director of Clinical Operations confirmed that the Activities Director had been hired on that date and did not meet the requirements to be employed as a qualified activity director. This deficiency had the potential to affect all residents in the facility except for 14 facility-identified residents (#3, #8, #12, #36, #45, #50, #51, #62, #67, #73, #78, #81, #82, and #89) who did not participate in facility activities. The facility census at the time was 91 residents.
Unqualified Activities Director Oversight
Penalty
Summary
The facility failed to ensure that its Activities Program was directed by a qualified Activities Director (AD). Record review showed that the AD did not sign attendance forms for several Resident Council meetings, and these meetings were instead facilitated and signed by an Activities Aid (AA). Interviews revealed that the DON was unaware of any concerns from these meetings and did not know if the AD met the required qualifications. The AA stated she had only recently been informed of her responsibility to share meeting minutes with management. Personnel file review indicated that the individual serving as AD was originally hired as social services staff and lacked documentation of certification or appropriate training for the AD role. The AD confirmed in an interview that she did not meet the qualifications for the position and had not enrolled in the necessary program due to a change in facility ownership. This deficiency had the potential to affect 32 residents interested in or participating in activities.
Unqualified Staff Assigned to Direct Activities Program
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, as required by the position description and regulatory standards. Review of the personnel file for the current Activities Director showed that she was originally hired as a Certified Nursing Assistant and later became an activity assistant before assuming the role of Activities Director. However, there was no evidence in her employee file to demonstrate that she met any of the required qualifications for the position, such as being a qualified therapeutic recreation specialist, a licensed activities professional, having the necessary experience, or having completed a state-approved training course. The Activities Director herself confirmed during interview that she did not possess the required qualifications and had been serving in the director role for several months. Further review revealed that the Activities Director only began a certified activities director course after assuming the position, and there was no indication that she had completed it. Interviews with the Divisional Director of Activities and the Regional Administrator confirmed that the Activities Director was not certified and did not meet the qualifications outlined in the job description. This deficiency was identified during a complaint investigation and had the potential to affect all residents in the facility.
Unqualified Activities Director and Inadequate Department Training
Penalty
Summary
The facility failed to ensure that the Activities Director (AD) was qualified for the position as required by the facility's job description and regulatory standards. Review of the AD's personnel file showed that the individual had only limited prior experience in activities, which did not meet the minimum qualifications outlined for the role. There was no evidence in the personnel file that the AD was a qualified therapeutic recreation specialist, licensed activities professional, occupational therapist, or had completed a state-approved training course. The AD confirmed in an interview that, although administration discussed the need for approved training, she declined to pursue it. Further interviews with activities aides revealed additional concerns related to inadequate training and poor communication within the activities department. Activities aides reported feeling overwhelmed, lacking proper orientation, and not receiving guidance from the AD. They described issues such as insufficient supplies, lack of planned events for special occasions, and unclear instructions regarding activities. The administrator confirmed that the AD did not meet the required qualifications for the position, and acknowledged ongoing issues within the department.
Unqualified Activities Director Placed in Charge of Activities Program
Penalty
Summary
The facility failed to ensure that the Activities Director was qualified for the position, as required. Personnel file review for the Activities Director showed no evidence of experience or certification to serve in this role, and the file did not contain a signed job description. Interviews with the Activities Director and Human Resource Manager confirmed that the Activities Director had no prior experience in activities and was not certified. The Administrator acknowledged awareness of the lack of certification but had not addressed the issue. The Corporate Director of Life Enrichment and Memory Care confirmed that the Activities Director was hired without the required qualifications and described the expectations for the department, including staff training and activity scheduling. This deficiency had the potential to affect all 54 residents in the facility, as the Activities Director was solely responsible for the activities program.
Unqualified Staff Directing Activities Program
Penalty
Summary
The facility failed to ensure that its activities program was directed by a qualified professional, as required by its own job description and regulatory standards. Review of the personnel file for the current Activity Director (AD) showed no evidence of appropriate qualifications or certification for the position. The AD was initially hired as an activity assistant and promoted to Activity Director after the previous director left, despite having no prior experience in an activity position and not being enrolled in a certification program at the time of promotion. The AD had attended a 13.5-hour training called Activity Director Bootcamp, but this did not count toward the required certification. The job description for the Activity Director position specified that certification through an accredited source was required. Interviews with the AD, the Administrator, and the Director of Clinical Services/Registered Nurse (DCS/RN) confirmed that neither the AD nor the DCS/RN held the necessary activity director certification. The DCS/RN, who had been overseeing the activities program since 2021, also lacked certification and only had limited experience in activity positions. Documentation showed that the AD was only enrolled in a certification program after surveyor inquiry, with enrollment confirmed on the day of the interview. This deficiency had the potential to affect all 56 residents in the facility.
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