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
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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: A resident reported the facility had been without an activity director for about a month. The ADM and regional clinical director confirmed there was no qualified activity professional in place, the newly hired director was not yet qualified, and OT would oversee the program until qualification was met. The regional clinical director later confirmed the activity program was not being overseen by a qualified person after the prior activity director left.
Activities program not directed by a qualified professional. Surveyors observed only music in the common area and one snack-making activity, with no activity director seen in the facility. The Administrator and Facility Manager confirmed the facility had no current activities director and no staff member with the required qualifications, while one resident said he was often bored and there was not much to do.
The facility allowed its activities program to be directed by an individual who did not meet the required qualifications for an activities director. Personnel records showed the activities director was hired without the necessary credentials, and this was confirmed by the Regional Director of Clinical Operations. This deficiency had the potential to affect nearly all residents who participated in facility activities, given the overall census and the small number of residents identified as non-participants.
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.
Activities Program Not Directed by a Qualified Professional
Penalty
Summary
The facility failed to ensure the activities program was directed by a qualified professional. Resident #55 stated on 5/5/26 that the facility had not had an activity director for about a month. On 5/6/26, the administrator and regional clinical director confirmed the facility did not have a qualified activity professional at that time, and they stated a new activity professional had been hired even though the new director who would be starting was not qualified. They also stated the program would be overseen by occupational therapy until qualification was met. On 5/7/26, the regional clinical director confirmed the activity program was not being overseen by a qualified person and that the previous activity director left on 3/18/26.
Activities Program Not Directed by Qualified Professional
Penalty
Summary
The facility failed to maintain an activities program directed by a qualified activities professional. During the annual survey, surveyors observed music playing in the common area throughout the days and one snack-making activity with residents, but no other activities were observed and no activity director was seen in the facility. The Administrator and Facility Manager confirmed that the facility did not have a current activities director and did not employ anyone with the required qualifications, stating that someone helped on weekends but did not meet the required qualifications. Resident #2 stated she did not have an issue with the activities because she mostly stayed in her room, watched TV, and did not wish to attend activities, and Resident #26 stated he was often bored and there was not much to do in the facility.
Unqualified Staff Member Directing Activities Program
Penalty
Summary
The facility failed to ensure its activities program was directed by a qualified professional, as required. Review of the personnel record for the Activities Director showed a hire date of 04/02/26 and further revealed that this individual did not meet the qualifications required to serve as an activity director in the facility. An interview with the Regional Director of Clinical Operations confirmed that the Activities Director had been hired on that date and did not meet the requirements to be employed as a qualified activity director. This deficiency had the potential to affect all residents in the facility except for 14 facility-identified residents (#3, #8, #12, #36, #45, #50, #51, #62, #67, #73, #78, #81, #82, and #89) who did not participate in facility activities. The facility census at the time was 91 residents.
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