Lack of Qualified Activities Director for Resident Activities Program
Penalty
Summary
The facility failed to ensure that its activities program was directed by a qualified full-time Director of Activities for all 45 residents. According to interviews with staff, the Director of Activities had been out on medical leave since February 2025, and no interim Director of Activities had been appointed. Certified Nursing Assistants (CNAs) were trained by a unit clerk to complete the Activities Evaluation in the electronic health record system and on paper, but there was no qualified individual overseeing the activities program. The Registered Nurse Manager confirmed that CNAs were responsible for assessing and conducting activities in the absence of a Director of Activities. The facility was unable to provide a job description for the Activities Director when requested. Review of the facility's policy indicated that the activities program should be under the direct supervision of an Activities Coordinator, who is responsible for planning, coordinating, and directing activities, as well as participating in resident assessments and care planning. The lack of a qualified Director of Activities meant that the program was not being supervised or managed according to facility policy, potentially impacting the quality and appropriateness of activities provided to residents.