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F0680
E

Unqualified Staff Directing Activities Program

Kerrville, Texas Survey Completed on 11-21-2025

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. Record review and interviews revealed that the individual serving as Activity Director did not possess the necessary qualifications, training, or certification. The Activity Director had been in the position for 4-5 weeks, had no prior experience, was not an occupational therapist or occupational therapy assistant, and was not enrolled in any training program for the role. The HR Director confirmed that there was no proof of education or training in the personnel file, and the Administrator acknowledged that the Activity Director was not currently registered for any required training and that no one else at the facility met the qualifications for the position. The facility's job description for the Activity Coordinator did not specify required qualifications, and the policy on the activity program did not address the qualifications for the Activity Director. The Administrator and Activity Director both stated that the current Activity Director was initially hired as an assistant and was performing the role on a trial basis, with intentions to pursue certification in the future. As a result, 72 out of 72 residents reviewed were affected by the lack of a qualified professional directing the activities program.

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