Failure to Accurately Assess and Document Resident Activity Preferences
Summary
The facility failed to ensure that the Activities Director accurately completed, directed, or delegated the accurate completion of the activities component of the comprehensive assessment for residents, particularly those with severe cognitive impairment. Review of facility documents, clinical records, and staff interviews revealed that for 28 residents with severe cognitive impairment, there was no attempt to obtain information on resident preferences from family, significant others, or staff interviews, as required when residents are unable to communicate their preferences directly. Instead, the assessments consistently documented that all activity preference questions were answered as 'Very Important' and that this information was obtained from the resident, even when the resident's cognitive status indicated they were unable to reliably communicate such preferences. Analysis of the Minimum Data Set (MDS) comprehensive assessments showed a pattern of uniform responses. Of the 100 assessments reviewed, 66 were completed by the Activities Director, with 92.4% of these having all answers marked as 'Very Important.' Similar patterns were observed in assessments completed by other staff, with a high percentage of uniform responses and little variation, regardless of the resident's cognitive ability. In several cases, residents had BIMS scores indicating severe cognitive impairment or were rarely understood, yet the documentation still reflected that all preferences were obtained directly from the resident and marked as 'Very Important.' Interviews with the Activities Director confirmed responsibility for completing the activities component of the MDS and acknowledged the uniformity of responses, attributing it to the answers provided during interviews. However, there was no evidence that alternative sources, such as family or staff, were consulted for residents unable to communicate their preferences. The deficiency was communicated to the Nursing Home Administrator, highlighting the facility's failure to follow required procedures for accurately assessing and documenting resident activity preferences, especially for those with severe cognitive impairment.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Activities Program Not Directed by a Qualified Professional: A resident reported the facility had been without an activity director for about a month. The ADM and regional clinical director confirmed there was no qualified activity professional in place, the newly hired director was not yet qualified, and OT would oversee the program until qualification was met. The regional clinical director later confirmed the activity program was not being overseen by a qualified person after the prior activity director left.
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 failed to ensure the Activities Program was directed by a qualified professional. Record review showed the Activities Director was hired without evidence of the required Activities Director course, prior experience, or qualifying credentials, and the DON stated there was no policy related to Activity Director qualifications.
Activities Program Not Directed by a Qualified Professional: Surveyors found the facility had an AD, but the NHA could not provide proof that the AD met qualification requirements or that an activities consultant provided oversight. The AD said this was her first activities position, she had not started the required course, and she was responsible for planning the resident activities calendar. Record review showed the AD completed activities records for a resident.
Activities Program Not Directed by a Qualified Professional: The facility failed to ensure the activities program was directed by a qualified professional. The AA stated she had been serving as the AD after the prior director left, but she had not completed a training course, had no corporate assistance with developing the activities program, and had not been trained in care planning or involved in activity care plans, QAPI, or quality improvement projects. The Administrator stated the AA was not the AD and was signed up for classes to obtain AD credentials.
Unqualified Activities staff directed resident activities. The Activities Assistant was the only person in the Activities dept and independently led an activity with 14 residents while not holding the required Activity Director certification. Interviews with the HR Coordinator, Activities Assistant, Administrator, and DON confirmed the Activities Director position was vacant, the Assistant was performing Director duties, and the job description required a certified Activity Director.
Activities Program Not Directed by a Qualified Professional
Penalty
Summary
The facility failed to ensure the activities program was directed by a qualified professional. Resident #55 stated on 5/5/26 that the facility had not had an activity director for about a month. On 5/6/26, the administrator and regional clinical director confirmed the facility did not have a qualified activity professional at that time, and they stated a new activity professional had been hired even though the new director who would be starting was not qualified. They also stated the program would be overseen by occupational therapy until qualification was met. On 5/7/26, the regional clinical director confirmed the activity program was not being overseen by a qualified person and that the previous activity director left on 3/18/26.
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.
Activities Program Not Directed by Qualified Professional
Penalty
Summary
The facility failed to ensure the Activities Program was directed by a qualified professional who met the required training and certification standards before assuming the role of Activities Director. Record review showed the Activities Director was hired on 10/20/25 and had a certificate dated 12/31/25 for Hospitality Management Studies, but there was no indication she had completed the Activities Director course. During an interview on 4/1/26 at 11:25 a.m., the Activities Director stated she had a certificate in hotel hospitality, had not completed the Activity Director course, was not aware it was necessary, did not have 2 years of prior experience, and was not a therapeutic recreation specialist or an activities professional. During an interview on 4/2/26 at 8:50 a.m., the DON stated she did not have a policy related to the Activity Director or qualifications.
Activities Program Not Directed by a Qualified Professional
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional. Surveyors found that the facility had an activities director, but the nursing home administrator was unable to provide documentation that the activities director had been enrolled in or had completed the required courses to be considered qualified. The administrator also could not provide documentation that the facility had employed an activities consultant to provide oversight to the activities department. Record review showed that the activities director completed the activities records for Resident #19. During interview, the activities director said she started working at the facility in September 2025, had never worked in a nursing facility before, knew she had to take a course to become a qualified activities director, but had not started it yet. She also said she did not have an activities consultant to help her and that she was responsible for planning the activities calendar for the facility's residents. The nursing home administrator stated that the activities director did not meet the requirements for the position and said she believed the facility met the requirements as long as the director was enrolled in a course.
Activities Program Not Directed by a Qualified Professional
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional. Review of the Activities Director job description showed that the activities program must be directed by a qualified professional, including a qualified therapeutic recreation specialist, an activities professional who is licensed or registered if applicable, an individual eligible for certification as a therapeutic recreation specialist or activities professional by a recognized accrediting body, a person with 2 years of experience in a social or recreational program within the last 5 years with one year full-time in a therapeutic activities program, a qualified occupational therapist or occupational therapy assistant, or someone who has completed a State-approved training course. During interview, the Activity Assistant stated she had been serving as the AD since the previous director left and had not yet completed a training course. She stated she did not have corporate assistance with developing an activities program, had not received training in care planning, had not been involved in developing or revising activity care plans, and did not attend QAPI meetings or participate in quality improvement projects. The Administrator stated the former AD’s last day was 08/07/25 and that the AA was not the AD, adding that the AA was signed up for classes in April to obtain AD credentials.
Unqualified Activities Staff Directed Resident Activities
Penalty
Summary
The facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional, and the Activities Assistant had not completed State approved training to direct facility activities. During an interview, the Receptionist stated the Activities Assistant was the only individual in the Activities department. During an observation, the Activities Assistant independently led an activity with 14 residents present, involving physical stretching, meditation, and prayer. During interviews, the HR Coordinator stated the activities department consisted of one Activities Assistant and a part-time assistant, and that the Activities Director position had been vacant since 2/20/2026. She stated the Activities Assistant would transition into the Activities Director position once she passed her certification course, and that the Administrator oversaw the operation and helped with the monthly calendar and supplies. The HR Coordinator also stated she was responsible for reviewing employee licenses and certifications, but was unaware of any policy requiring the Activities Assistant to possess a certificate. The Activities Assistant stated she did not have certification to be an Activity Director and described responsibilities that included conducting activities, transporting residents to and from activities, providing in-room activities, and ensuring residents did not fall during activities. She stated the previous Activities Director had resigned about 2 weeks earlier and that she was completing the activities calendar going forward. The Administrator stated the Activities Assistant had a conditional offer for the Activities Director position but did not currently possess the required certificate, and the DON stated the Activities Assistant had been facilitating activities with instruction from the regional Activities Director. Record review showed the Activity Assistant job description reported directly to the Activity Director, and the Activity Director job description stated the position must be a certified Activity Director.
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