Unqualified Activities Director and Inconsistent Program Management
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, as required by regulations. The Activities Director (AD) had only been in the position for two weeks and previously worked as a unit clerk for several years. The AD was unfamiliar with key aspects of the role, such as the process for delivering a daily newspaper to a resident and the documentation of resident activity participation. Additionally, the AD had not attended any Quality Assurance or resident care plan meetings, indicating a lack of experience and training for the position. The facility had not had a consistent Activity Director since July, and the current AD was not qualified according to the job description, which required a Bachelor's degree in a relevant field and 2-3 years of experience. The Staffing Coordinator/Lead Certified Nursing Aide (SC/LCNA) was identified as the new AD, but she had not yet completed the necessary training or attended relevant meetings. This lack of a qualified and consistent Activities Director had the potential to affect all residents in the facility, as evidenced by the issues observed during the survey.
Plan Of Correction
1: The facility was successful in hiring a full-time certified U.S. FOIA (b) (6) with a start date of NU Exec Order 26.4b1. 2: All residents had the potential to be affected by the deficient practice. 3: The non-certified U.S. FOIA (b) (6) who is now a U.S. FOIA (b) (6) and the other activity staff were made aware of the hiring and were also educated that the certified AD will be responsible for completing the assessments. 4: The Administrator / designee will audit the new director's performance in general and specifically with completing the assessments accurately and timely. Results will be reported to the QAPI committee for review and action as necessary. 5: 3-3-2025. Element One: Corrective Actions The facility hired a full-time U.S. FOIA (b) (6) who started employment on NJ Ex Order 26.4(b)(1). The facility had sister facility Certified Activity Directors review, revise as needed, and sign the most recent APR for each resident and then review and update the care plan as appropriate to ensure the assessment and care plan met the current interests, abilities, and preferences of each resident. Element Two: Identification of at-risk Residents All residents had the potential to be affected by this practice. Element Three: Systemic Change All residents and facility staff were informed of the hiring of a Certified Activity Director and all activity staff were re-educated about their role and that of the CAD for completing the assessment and updating care plans. Element Four: QAPI A sister facility CAD/designee will monitor the new certified activity director's performance through audits of 10% of APR assessments weekly for two weeks, then monthly for two months to ensure they are properly completed and signed, and the care plan has been updated. Results will be reported to the QAPI committee for review and action as necessary. Completion Date: 3-5-2025.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Missing Qualified Activities Professional: The facility did not have a qualified Activities Professional to direct the activities program, and the AD position remained open while residents reported that preferred activities such as bingo, ice cream socials, group crafts, and visiting musicians had not been offered for the past 2 months. Record review showed inconsistent activity calendars, and interviews with HR, corporate HR, and the Administrator confirmed the facility was still seeking a qualified candidate and had no one meeting the AD requirements.
Activities Program Not Directed by Qualified Professional: The facility failed to ensure its activities program was directed by a qualified professional. The Activity Director stated she was not certified, had only completed part of an online training program, and previously worked as the facility receptionist with no prior activity director background. The Administrator confirmed the Activity Director was not licensed, was unsure of her certification status, and stated the facility had been without a certified Activity Director since 11/2025; no policy for the Activity Director was available.
Activities Program Not Directed by Qualified Professional: The facility did not have a qualified AD to direct the activities program. The BOM stated she kept residents busy, changed activities based on resident preference, and did activities with them, while the DOR said she oversaw activities, provided exercises and one-on-one activities, and used resident council input. The ADM stated the facility had been without an AD for 2 months and had relied on the BOM, HRD, and DOR to cover activities.
Activities Program Not Directed by Qualified Professional: The facility did not have a qualified Activity Director in place, and residents reported not receiving the July activity calendar. A resident and a confidential resident group stated there was no longer an activity director, and the Administrator had to sit in at resident council because the role was vacant. The DON confirmed resident council was affected, and record review found no documentation that the facility had an Activity Director with the required certification, approved training, licensure, or other qualifying documentation.
Activities Program Not Directed by a Qualified Professional: The facility failed to ensure the activities program was directed by a qualified professional for a census of 106 residents. The Activities Director had previously worked as the front desk receptionist and was on leave, and the Administrator stated that neither the Activities Director nor the Administrator had the qualifications required to direct the program. The Administrator was covering the role and had education in Psychology, Business, Public Administration, and Health Care, but no experience in a social, recreational, or therapeutic activities program.
The facility failed to ensure its activities program was directed by a qualified professional after the Activity Director left for another department and the position remained vacant. An unlicensed/uncertified former Activity Director with a lapsed certification was providing part-time group activities while the ADMIN confirmed no certified Activity Director was on staff and the facility was recruiting.
Missing Qualified Activities Professional
Penalty
Summary
The facility failed to have a qualified Activities Professional in place to direct its activities program for the previous 12 weeks. The report states there was no qualified Activity Director from 5/12/2026 through the survey exit date of 08/12/2026, and the position remained open. Record review showed the facility did not have an activities professional or activities director, and the activity calendars for June and July 2026 did not show regularly consistent activities scheduled for residents. During interviews, ten random residents stated that activities of interest to them, including bingo, ice cream socials, group crafts, and visiting musicians, had not been offered in the last 2 months. The HR D stated she had been in her position since 7/20/2026 and that the facility had been seeking to employ an activity director since she assumed HR responsibilities. The CHR E stated the AD position was open and the facility was actively seeking a qualified candidate through advertisements, word of mouth, and internet job postings. The Administrator stated he had interviewed several candidates but found them unemployable, and that he was considering current staff for activity director training even though none were registered for training at the time. The facility policy titled Individualized Activity Programs stated the Activity Director and staff will provide individual programming to meet individual needs and interests.
Activities Program Not Directed by Qualified Professional
Penalty
Summary
The facility failed to ensure that its activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional licensed or registered by the State. During an interview on 08/11/2026, the Activity Director stated that she had not obtained certification as an activity director, had started online training in February 2026, had completed 8 of 12 modules, and could not obtain an online transcript of the course at that time. She also stated that before taking the full-time Activity Director position, she had worked as the facility's receptionist and assisted with medical records and did not have prior training or background as an activity director. During an interview on 08/12/2026, the Administrator stated that the Activity Director was not licensed and that she was not sure where she was in the certification process. The Administrator said she was aware the Activity Director had found a school but was not sure she had started classes, and that she would need to make sure she was enrolled online. She also stated that a regional corporate consultant currently oversaw the Activity Director's work and that the facility had been without a certified Activity Director since 11/2025. When asked for a policy for the Activity Director, the Administrator stated that if she did not provide one, then she did not have one.
Activities Program Not Directed by Qualified Professional
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 licensed or registered by the State. During interview, the BOM stated that because the facility did not have an AD, she kept residents busy and did activities with them, changed activities if residents did not want what was on the calendar, and asked residents during Resident Council Meetings what they preferred to do. She also stated the DOR assisted with physical exercises and that, without an AD to oversee activities, there was a potential for residents to become bored from not having any activities to do. The DOR stated the facility did not have a qualified AD and that she oversaw activities with the BOM to ensure engagement based on residents' abilities. She stated she participated two to three times a week and provided one-on-one activities on other days, and that activities were based on input from resident council meetings. The ADM stated the facility had not had an AD for 2 months, that he had replaced the prior AD with a dietary aide who signed up to become certified but left, and that the BOM and HRD did activities with residents. He stated the DOR would officially start covering activities and the BOM would manage activities under the DOR until an appropriate AD could be secured. Record review showed the facility's policies required activity programs designed to meet each resident's needs and interests.
Activities Program Not Directed by Qualified Professional
Penalty
Summary
The activities program was not directed by a qualified professional because the facility did not have a qualified Activity Director in place. During interview, an anonymous resident stated that he did not receive an activity calendar. A confidential group of residents stated they were aware there was no longer an activity director in the facility, that they had not received the July 2026 activity calendar, and that the Administrator had to sit in at their monthly resident council meeting because there was no Activity Director. The DON stated she knew there was no activity director and that resident council was affected because there was no one to keep minutes or help assemble the meeting, and residents missed discussion of resident rights. The Administrator stated the facility did not have an activity director and that the Activity Director was responsible for activities and resident council. Record review showed no documentation that the facility had an Activity Director with certification, completion of an approved training course, qualifying licensure, or other documentation showing the required qualifications. The facility policy stated each facility would have a director responsible for recreation services who was qualified according to state requirements.
Activities Program Not Directed by a Qualified Professional
Penalty
Summary
The facility failed to ensure that its activities program was directed by a qualified professional for a census of 106 residents. During interview, the Administrator stated that the Activities Director started in mid-May 2026 but had been on leave since the beginning of June 2026, and that this staff member did not have the qualifications required to direct the activities program. The Administrator also stated that the Activities Director had previously worked as the front desk receptionist and that the facility was registering the staff member for an activities training program in the fall. The Administrator further stated that they were covering for the Activities Director, but also acknowledged that they did not have the qualifications required to direct the activities program. Review of the Administrator’s resume showed education in Psychology, Business, Public Administration, and Health Care, but no experience in a social or recreational program or therapeutic activities program.
Activities Program Not Directed by a Qualified Professional
Penalty
Summary
The facility failed to ensure the activities program was directed by a qualified professional. During interviews, the ADNS, ADMIN, and DS stated that the former Activity Director had recently transitioned to the dietary department, leaving the Activity Director position vacant. The ADMIN stated the facility did not have a certified Activity Director on staff and was actively recruiting. CNA D stated his Activity Director certification had lapsed about a year earlier, that he had returned to help with the activities program on a part-time basis, and that he was providing group activities in the afternoon while the position remained unfilled. The DS stated that when he had served as the former Activity Director, he provided group and in-room activities, visited residents throughout the week, and documented those activities in the electronic medical record. He also stated that activities were necessary to promote residents’ physical and emotional well-being. Record review of the facility’s Activities Program policy stated that the activities program is directed by a qualified professional. The report shows that, at the time of the survey, the facility’s activities program was operating without a qualified Activity Director in place.
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