F0680

E

Unqualified Activities Director and Inadequate Position Requirements

Lakeside, Arizona Survey Completed on 11-19-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that the activities program was directed by a qualified professional as required by federal regulations. Personnel file review showed that the Activities Director was hired to manage all aspects of the activities program, including development, implementation, supervision, evaluation, completion of the activities component of the comprehensive assessment, and development of related care plan goals and approaches. The facility job description for this position listed only basic employment requirements such as background check, fingerprint clearance, TB clearance, post-hire health screening, and English proficiency, and did not include the qualification requirements specified in the State Operations Manual for an Activities Director.

Review of the Activities Director’s resume showed prior employment as a Senior Research Associate/Administrative Director and educational credentials including a Master in Education and a Bachelor of Arts in Music Therapy, Music Education, and Psychology, but did not demonstrate that the individual met the specific qualification requirements outlined in the State Operations Manual. The personnel file indicated that the Activities Director applied for Activity Director Certification several months after hire and that the application was still under review. HR staff confirmed that the Activities Director had not previously held an activities position and that her role at the facility included overseeing activities for residents. HR and the DON both stated that they rely on the job description to determine qualifications and that there was no hiring policy in place, and the facility did not provide a hiring policy when requested by surveyors.