Health inspection·December 14, 2022

F 0680 Ensure the activities program is directed by a qualified professional. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure their activities program was directed by a qualified professional for 1 of 1 facility reviewed for Activity Director Qualifications. Residents Affected - Some The facility did not ensure the Activity Director completed the required training to serve as the director of the activities program. This failure could place residents at risk of not having an overall skilled and knowledgeable Activities Director to direct an effective activities program, which could result in the residents not receiving activities to meet their needs. Findings include: Record review of the Activity Director's Personnel record revealed her hire date was 01/03/22 and there was not any documentation of certification or Activity CEU's or therapist certification in her file. Interview on 12/12/22 at 10:15 am, the Administrator stated their Activity Director was currently working to get her Activity Director Certification and they had no other Certified AD who worked at this facility. Interview on 12/13/2022 at 4:32 pm, the Activity Director stated she started working at this facility in January 2022 and did not have her Activities Director certification. She stated the Administrator told her when she became the AD, she would have to complete a certification class. She stated the MEPAP course was a self-paced online program she started about six months ago. She stated she did not have a bachelor's degree and was not an Occupational Therapist and Occupational Assistant. She stated she knew what she was doing as an AD and talked to the SW or MDS nurse if she had any questions about anything. She stated she planned the resident's day to day activities such as cooking, coloring, baking and anything they could have potentially done in the past. She stated she graduated from high school last year and worked at a restaurant and as the receptionist at this facility before getting the AD position. She stated she had completed 85% of the MEPAP certification course. She stated not being a certified AD could cause her to be incapable of doing her job effectively and could also lose this job if she did not get certified. She stated if she had the opportunity to have completed the MEPAP course before she became the AD she would have done so. Interview on 12/14/22 at 3:25 pm, the Administrator stated the AD started working at this facility as a receptionist a year ago and she became the AD around February or March 2022. He stated he was aware the AD had to be certified and the facility's AD started her Activity Director Certification in (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 6 Event ID: 676104 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676104 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grapevine Medical Lodge 1005 Ira E. Woods Parkway Grapevine, TX 76051 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)