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Based on review of policy and procedure and staff interview, the facility failed to ensure that it provided an ongoing activities program directed by a qualified professional designed to meet, in accordance with the comprehensive assessment, the interests and the physical , mental, and psychosocial well-being of each resident and.


Findings Include:


Review of the facility's "Activities Program" swingbed policy revealed, "Policy: The resident may meet with and participate in activities of social, religious and community groups at his/her discretion, unless there are written restrictions documented by the physician in the medical record."


Interview conducted with the Risk Manager on 6/10/15 at 2:05 p.m. revealed that the facility did not have a director of activities for the swing bed unit. She stated, "We have talked about it and we know that we needed one, but we do not have one." There was no policy presented pertaining to the Director of Activities.