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:
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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