Dawn Worsley, LNHA, ACC

Under CMS regulations for skilled nursing facilities (42 CFR §483), both the Nursing Home Administrator (NHA) and the Director of Nursing (DON) have defined responsibilities for ensuring resident quality of life, protection of resident rights, and access to meaningful activity programs. While the Director of Activities leads the design and implementation of activity services, CMS expects close coordination among all three roles.

Role of the Nursing Home Administrator (NHA)

CMS holds the Nursing Home Administrator ultimately responsible for facility-wide compliance with federal regulations, including those related to resident activities, quality of life, and resident rights.

Key CMS Responsibilities of the Administrator

1. Ensuring Quality of Life (§483.24)
CMS requires facilities to provide an environment that enhances each resident’s dignity, autonomy, and psychosocial well-being. The administrator must ensure:

• Adequate staffing and resources for the activity department

• Policies that support resident choice, independence, and engagement

• Programs that reflect resident preferences and cultural backgrounds

2. Oversight of Activity Programs
While the administrator does not design daily activities, CMS expects them to ensure that:

• A qualified activity professional (such as NCCAP-certified staff) is employed

• Activity services are delivered in accordance with assessed resident needs

• The program is meaningful, individualized, and compliant with regulations

3. Protection of Resident Rights (§483.10)
The administrator ensures residents have the right to:

• Choose how they spend their time

• Participate—or decline participation—in activities

• Access programs that support physical, mental, and psychosocial well-being

This includes ensuring residents are not excluded from activities due to diagnosis, disability, or staffing limitations.

4. Supporting Interdisciplinary Collaboration
CMS expects administrators to foster collaboration among nursing, activities, therapy, social services, and dietary departments. The administrator sets the tone that activities are essential to care, not optional.

Role of the Director of Nursing (DON)

The Director of Nursing is responsible for clinical oversight and ensuring nursing services support resident safety, function, and quality of life—including participation in activity programs.

Key CMS Responsibilities of the DON

1. Integration of Activities into Clinical Care (§483.21)
CMS requires care plans to be interdisciplinary. The DON must ensure:

• Nursing staff support resident attendance at activities

• Activity goals align with clinical care plans

• Nursing assessments reflect psychosocial and functional needs

2. Fall Prevention and Functional Support (§483.25)
Activities are a key component of fall reduction and mobility maintenance. The DON ensures:

• Nursing staff collaborate with activities to promote safe movement

• Residents are encouraged—not restricted—from participating in activities unless clinically indicated

• Activity programs support strength, balance, and cognition

3. Resident Rights and Dignity
The DON ensures nursing staff respect resident rights by:

• Honoring resident choice regarding activity participation

• Avoiding unnecessary restraints or overuse of psychotropic medications that limit engagement

• Supporting dignity and independence during activities

4. Education and Communication
The DON ensures nursing staff understand the value of activity programming and communicate changes in condition to the Director of Activities to allow timely program adjustments.

Role of the Director of Activities (In Coordination)

CMS defines activities as therapeutic, purposeful interventions that support physical, mental, and psychosocial well-being. The Director of Activities is responsible for:

• Conducting comprehensive activity assessments

• Developing individualized activity care plans

• Implementing meaningful programs aligned with resident goals

• Documenting outcomes that support quality measures

Coordination Is a CMS Expectation

CMS does not view activities as a standalone department. Instead, surveyors look for evidence that:

• Nursing supports activity participation

• Administration provides adequate resources

• Activities are integrated into the interdisciplinary care plan

How These Roles Work Together Under CMS

Why This Matters

CMS survey outcomes, quality measures, and resident satisfaction depend on how well these roles collaborate. When administrators and nursing leadership actively support the activity program, facilities see:

• Improved quality of life outcomes

• Reduced falls and behavioral symptoms

• Stronger survey results

• Greater resident and family satisfaction

A coordinated approach ensures that activity services are recognized as a core component of skilled nursing care, fully aligned with CMS regulations