Lack of Qualified Activity Director
Summary
The facility failed to ensure the activity program was directed by a qualified professional from November 17, 2023, through the survey exit date of March 19, 2024. During the entrance conference on March 12, 2023, the Administrator confirmed that the facility did not have an Activity Director. Interviews with three Activity Assistants revealed that none of them had previous experience in activities or long-term care, and none were responsible for meeting with residents to determine activity preferences, completing assessments of activity needs, or creating care plans for residents. Activity Assistant #2 and #3 had started in January 2024 with no prior experience, and Activity Assistant #3 was transitioning to the laundry department. Activity Assistant #1, who started in 2019, was a part-time assistant with no oversight responsibilities for the activity department.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
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.
The facility assigned an unqualified staff member to the Activities Director position without verifying required credentials or enrollment in a state-approved training course, as confirmed by personnel file review and staff interviews. This failure had the potential to impact all residents in the facility.
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.
Unqualified Staff Assigned as Activities Director
Penalty
Summary
The facility failed to ensure that its activities program was directed by a qualified professional, as required by regulation. Review of the personnel file for the current Activities Director showed that she was originally hired as a receptionist and later transferred to the Activities Director position. The job description for the Activities Director role specifies that the individual must meet certain qualifications, such as being a qualified therapeutic recreation specialist, a licensed activities professional, having relevant experience, or having completed a state-approved training course. However, there was no evidence in her employee file to demonstrate that she met any of these qualifications. Interviews with the Human Resources Director, the Administrator, and the Activities Director herself confirmed that she did not possess the required qualifications and was not enrolled in a state-approved training course at the time of her appointment. The Activities Director also stated she was unsure how to enroll in the necessary course and had not received information about enrollment until after the deficiency was identified. This lack of a qualified professional in the Activities Director role had the potential to affect all 40 residents in the facility.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
