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F0680
E

Unqualified Activity Director Leading Activities Program

Waco, Texas Survey Completed on 07-15-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that its activities program was directed by a qualified professional, as required. The individual serving as the Activity Director (AD) had been in the role since March 2025, following the termination of the previous AD in February 2025. The current AD reported that she had previously worked as an assistant AD and CNA, and had not yet started her certification process for the AD position. Although she stated she was enrolled in the appropriate class, she was unable to provide any evidence of enrollment during the survey. The Administrator (ADM) confirmed that the current AD was promoted from the assistant position and believed she was in the process of obtaining the necessary certification, with plans for reimbursement upon completion. However, the ADM did not have any documentation to verify the AD's enrollment in the required classes. Additionally, the facility did not have a policy regarding the activities program or the qualifications for the activities director. Review of the job description indicated that the AD should be a qualified therapeutic recreation specialist, licensed or registered as applicable by the state, which was not met in this case.

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