Based on review of facility policy, personnel records, and staff interview, it was determined that the facility failed to ensure that the Activities Department had a qualified director to oversee the activities program.Findings include: The facility Activities Director employee job description indicated; The primary purpose of the job position is to plan, organize, implement, evaluate and direct the Activity Programs in accordance with the current federal, state, and local standards governing the facility and as directed by administrator, to ensure that the emotional, recreational, and social needs of the residents are met and maintained on an individual basis. Review of Activities Director Employee E1's personnel record indicated she was hired on 1/9/25. …
F680 citations in Pennsylvania
Quality of Life and Care Deficiencies
Ensure the activities program is directed by a qualified professional.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Pennsylvania cites F680 more often than its own record predicts
2.13 times the share F680 takes of citations nationally.
Of every deficiency written in Pennsylvania in 2025, this is the portion that was F680.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Pennsylvania surveyors wrote
F680 findings written in Pennsylvania, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on review of facility employee personnel records and staff interview, it was determined that the facility failed to ensure that the facility's activities program was directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional. Findings included: Interview with employee 3 (activities assistant) on December 5, 2023, at approximately 9:30 AM revealed that she was currently acting as the facility activities director. Employee 3 confirmed she was not yet a qualified activities professional and was hoping to complete a program to become a qualified activities professional in six months. …
The short window
Recent years
| Year | Share of Pennsylvania citations | vs expected |
|---|---|---|
| 2023 | 0.41% | 4.24× |
| 2024 | 0.07% | 0.84× |
| 2025 | 0.15% | 2.13× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Pennsylvania surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction