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:
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.
Activities program not directed by a qualified professional. The Activities Director reported no prior activities experience, no training, no shadowing, no assistant, and no access to another AD for consultation. The Administrator stated the AD was not certified and had not been enrolled in a certification course, while the job description did not list educational requirements and the facility lacked a usable activities policy.
Activities program was not directed by a qualified activities professional. The Activity Director had no documentation showing she met the required qualifications and stated she was not certified or formally trained for the role. The Administrator said CNAs were expected to help with resident engagement, but there was no process to verify evening or weekend activities, 1:1 visits were not being documented, and weekend activities were not being tracked. HR confirmed no formal activity-related training had been provided to aides or CNAs, and the CNA position was vacant.
A facility failed to ensure its activity program was directed by a qualified professional after the Activities Director position became vacant. No monthly activities calendar was maintained or posted, activities were mainly held on the second floor, and no organized activities were observed on the third floor. A cognitively intact resident said residents had tried to organize activities themselves because formal activities were not occurring, and staff confirmed the Activities Assistant had no formal training and had not been trained on the duties of the role.
Activities Program Not Directed by a Qualified Professional: The facility failed to ensure its activities program was directed by a qualified professional after the Activity Director abruptly quit and the position remained vacant. The Assistant Activity Director, who was not licensed or registered as a qualified activities professional, was carrying out the AD duties, including scheduling individual and group activities, while the Administrator acknowledged the facility was in non-compliance and the Regional Nurse Consultant stated there was no policy specific to the AD role.
Activities program not directed by a qualified professional. The Administrator stated the Activity Director had quit and an Activities Assistant was filling the role. The acting Activities Director said she had only been in the position for a few weeks, did not have the required certification or license, and was not in a training program to become licensed.
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.
Activities Program Not Directed by Qualified Professional
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional. Record review of the facility assessment dated [DATE] showed that staffing needs required an Activities Director. During interview, the Activities Director stated she had previously worked as a housekeeper and cashier and had no prior experience working with activities or as an Activities Director. She stated she was still learning the job and her duties, had no assistant, had not received training on how to be an Activity Director, had not completed shadow work, and did not have another Activity Director to consult. The Activities Director also stated she had not taken any training courses and was not enrolled in any, although a course had been discussed with the Administrator. She stated the Administrator told her she would have to pay for the training herself and that the course cost approximately $500, which she could not afford. The HR Director stated she had not hired or participated in hiring the Activities Director. The Administrator stated the Activities Director was not certified and that, to her knowledge, the requirement was only a high school diploma. She also stated she knew the Activities Director needed to be certified but had not enrolled her in a course because staffing, safety, and resident care were her focal point. The Activities Director job description listed preferred experience in office work, nursing home work, and supervision, but did not list educational requirements. The RCN stated the facility did not have a policy for the Activities Director, and the activities program policy provided by email could not be opened.
Activities Program Not Directed by Qualified Professional
Penalty
Summary
The facility failed to ensure its activities program was directed by a qualified activities professional. Review of the Activity Director job description showed the position was responsible for planning, organizing, developing, directing, and implementing the overall activity department, and required the director to meet specific qualifications such as being a qualified therapeutic recreation specialist, a licensed activities professional, having qualifying experience in a patient activities program, being a qualified OT or OTA, or completing an approved training course. However, review of the personnel file for Activity Director #192 found no documentation showing she met the required qualifications, and the facility roster showed she was the only activity staff member. Interviews confirmed the lack of qualification and oversight. The Administrator stated CNAs were expected to assist residents to and from activities and follow the activity calendar, but acknowledged there was no process to verify activities were occurring during evenings and weekends. Activity Director #192 stated she was not certified for the role and had not received formal training specific to the position, that CNAs/Aids were responsible for resident engagement after 3:00 P.M. and on weekends, and that there was no current process to verify those activities were completed. She also stated one-to-one activity visits were not being documented as required and weekend activities were not being tracked. The HRD confirmed the facility had not provided formal activity-related training for Activity Aides or CNAs responsible for resident engagement, and the CNA position had been vacant since 04/07/26.
Activity Program Lacked Qualified Direction and Oversight
Penalty
Summary
The facility failed to provide direction and oversight of the activity program by ensuring a qualified professional directed the development, implementation, and coordination of resident activities. The Activities Director position became vacant, and the facility did not maintain leadership of the department. Staff assigned activity responsibilities were not trained or competent to perform the duties of the position, and basic components of the program were not maintained, including the development and distribution of a monthly activities calendar for May 2026. Record review showed residents on the third floor had limited opportunities to participate in organized activities and minimal documented activity attendance. Observation during the survey found no activities calendar posted in common areas or in the elevator, and no organized activities occurring on the third floor. R3, who was cognitively intact with a BIMS score of 15, stated she and another resident had tried to organize activities themselves because no formal activities were occurring, that she never saw the Activities Assistant on the third floor, did not receive an activities calendar, and was not informed about activities elsewhere in the facility. Staff interviews confirmed activities were mainly occurring on the second floor, that the facility had not had an Activities Director since April 2026, that the Activities Assistant had no formal activities training and had not received training on the responsibilities of the position, and that the monthly calendar had not been printed or distributed.
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 who was a qualified therapeutic recreation specialist or an activities professional licensed or registered by the State. During interview, the Administrator stated that the Activity Director had recently quit and that the position had been vacant for a few weeks, while the Assistant Activity Director stated that the Activity Director quit abruptly at the beginning of April 2026. The Assistant Activity Director also stated that she was neither licensed nor registered as a qualified activities professional. The Assistant Activity Director reported that she was responsible for carrying out the duties of the former Activity Director, including scheduling both individual and group activities, and that she felt overwhelmed by those responsibilities. The Administrator stated that he was actively trying to fill the position, had an advertisement out for the job, and was considering sending the Assistant Activity Director to school for certification. He also stated that the Assistant Activity Director had been directing the activities program and that he understood the facility was in non-compliance. The Regional Nurse Consultant stated that the facility did not have a policy specific to the activity director and followed state regulations for the requirement.
Activities Program Not Directed by a Qualified Professional
Penalty
Summary
The facility failed to employ a certified Activities Director. On 5/11/26 at 10:45 AM, the Administrator stated the facility's Activity Director had quit and the Activities Assistant was filling the position for now. On 5/13/26 at 2:10 PM, the acting Activities Director stated she had only been in the position for a few weeks to see if she wanted to take it, and she said she did not have the certification or license and was not in a training program to be licensed.
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