Facility Lacks Qualified Full-Time Social Worker
Summary
The facility failed to employ a qualified full-time social worker to meet the psychosocial, mental, and behavioral health care needs of its residents, as identified during a recertification survey. The survey, conducted from October 28 to October 30, 2024, revealed multiple concerns regarding the facility's social work practices, including mood and behavior management, psychotropic medication, psychosocial assessments, and processes for completing advance directives and coordinating decision-makers. Interviews with the Director of Nursing (DON) and Staff 'D' confirmed that Staff 'D' was the only social worker employed at the facility, which is licensed for 179 beds. Staff 'D' reported that they had been working as a social worker since January 2024 but were not currently licensed, with their last license having expired in 2019. The facility's Administrator was aware of Staff 'D's lack of licensure but believed, based on advice from other facilities and their corporate team, that a license was not necessary. The Administrator confirmed that the last licensed social worker was employed until July 5, 2024, and acknowledged the difficulty in filling the social worker role. The surveyors identified concerns with the facility's hiring of a non-licensed individual for the social worker position, which could potentially lead to unmet psychosocial needs of the residents.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility, with a census of 135 residents, failed to employ a Licensed Social Worker (LSW) as required. Instead, a Social Work Consultant (SWC) without a social work license was providing services. The Administrator mistakenly believed the SWC was licensed and only realized the error after requesting her credentials. This deficiency was identified during a complaint investigation.
The facility failed to ensure that a social worker hired for a 126-bed facility had the required one year of supervised experience in a healthcare setting. The personnel file lacked evidence of such experience, and interviews with staff confirmed the absence of documentation. This deficiency potentially affected all 115 residents.
The facility did not employ a full-time, qualified social worker, affecting all 116 residents. The last social worker was hired and terminated within a few months, and the Administrator incorrectly believed the facility was licensed for fewer beds than required for this position.
The facility did not employ a full-time, qualified social worker, affecting 139 residents. The Social Service Director had a degree in business administration, not in social work or a human services field. The last licensed social worker left in December 2024, and interviews confirmed the absence of a licensed social worker during the survey.
The facility failed to employ a qualified social worker despite having over 120 certified beds. SSD #320, introduced as the new social worker, had a Master's degree but had not passed the State licensing exam and was not licensed. The Administrator was aware of this at the time of hiring. The job description required a Bachelor's Degree, supervisory experience, and ACSW registration, which SSD #320 did not meet. This deficiency potentially affected all 109 residents.
The facility failed to employ a full-time, qualified social worker, affecting 90 residents. The Social Services Designee lacked the required qualifications, and the Activities Director, identified as handling social services, had no relevant experience. The Administrator confirmed that neither were Licensed Social Workers (LSWs), and oversight was provided by a Corporate Social Services Designee who was also not an LSW.
Facility Lacks Licensed Social Worker for Resident Services
Penalty
Summary
The facility failed to employ a Licensed Social Worker (LSW) to provide services to its residents, despite having a census of 135 residents, which exceeds the threshold of 120 beds requiring a full-time social worker. Observations revealed that a Social Work Consultant (SWC) was providing services, but there was no information posted regarding her license to practice as a social worker. Interviews with the Administrator and the SWC confirmed that the SWC had a bachelor's degree but was not a licensed social worker. The Administrator admitted to mistakenly believing the SWC was licensed and only discovered the lack of licensure upon requesting her credentials. This deficiency was identified during the investigation of Complaint Numbers OH00163464 and OH00163460.
Lack of Supervised Experience for Social Worker
Penalty
Summary
The facility failed to ensure that the social worker hired for a facility with 126 beds had the proper qualifications, specifically one year of supervised social work experience in a healthcare setting. The personnel file for the social worker, who held a Master's in Social Work, did not provide evidence of the required supervised experience. Although a reference check from a previous LTC facility was included, it did not confirm whether the social worker was supervised during her tenure there. Interviews with the Administrator, Social Service Liaison, and Director of Nursing confirmed the lack of evidence regarding the social worker's supervised experience prior to her employment at the facility. This deficiency had the potential to affect all 115 residents residing in the facility.
Failure to Employ a Qualified Full-Time Social Worker
Penalty
Summary
The facility failed to employ a full-time, qualified social worker, which is a requirement for facilities with more than 120 beds. This deficiency had the potential to affect all 116 residents residing at the facility. The employee file review revealed that the most recent social worker was hired on September 18, 2024, and terminated on December 19, 2024. An interview with the Administrator confirmed that the facility did not have a qualified social worker available for the residents. The Administrator mistakenly believed that the facility was only licensed for 119 beds.
Facility Lacks Qualified Social Worker
Penalty
Summary
The facility failed to employ a full-time, qualified social worker, which is a requirement for facilities with more than 120 beds. This deficiency potentially affected all 139 residents in the facility. The Social Service Director, hired on July 22, 2022, held a bachelor's degree in business administration, not in social work or a human services field as required. The last licensed social worker was employed from September 23, 2024, to December 6, 2024, but was no longer with the facility. Interviews with the Social Service Director and the Administrator confirmed the absence of a licensed social worker at the time of the survey. This deficiency was identified during a complaint investigation.
Facility Lacks Qualified Social Worker for Over 120 Beds
Penalty
Summary
The facility failed to ensure a qualified social worker was on staff, despite having over 120 certified beds, which is a requirement. The deficiency was identified through a review of Resident Council meeting minutes, staff interviews, and examination of the Social Services Designee (SSD) #320's credentials and work history. SSD #320, who was introduced as the facility's new social worker, had a Master's degree in Social Work but had not passed the State licensing board exam and was not a licensed social worker at the time of the survey. SSD #320 confirmed she would not retake the exam until January 2025 and had not been supervised by a licensed social worker in her previous roles. The facility's job description for the Director of Social Services required a minimum of a Bachelor's Degree in Social Work, two years of supervisory experience in a medical facility, and registration as an Academy of Certified Social Workers (ACSW) member in good standing with the National Association of Social Workers (NASW). However, SSD #320's resume did not indicate she met these requirements. The Administrator acknowledged hiring SSD #320 with the knowledge that she had not yet obtained a social work license, expecting her to pass the exam in the summer of 2024, which she did not. This oversight had the potential to affect all 109 residents in the facility.
Facility Lacks Qualified Full-Time Social Worker
Penalty
Summary
The facility failed to employ a full-time, qualified social worker, which had the potential to affect all 90 residents. The facility, with 127 certified and licensed beds, had a Social Services Designee (SSD) who did not meet the qualifications outlined in the job description. SSD #611, hired on 03/28/21, had attended college but did not earn a degree and had no documented history of long-term care experience. The job description required two years of experience in long-term care and preferred a Licensed Social Worker (LSW). Additionally, the Activities Director (AD) #502, who was identified as handling social services, had a degree in healthcare administration but no social services experience. Interviews with the Administrator revealed that SSD #611 had moved to a corporate position, and AD #502 was training to fill the social services role. SSD #611 continued to assist the facility twice weekly, with Corporate Social Services Designee (CSSD) #902 providing oversight and assistance once every week or every other week. LSW #900 from a sister facility initially assisted once a week but now only helped as needed. The Administrator confirmed that neither AD #502 nor SSD #611 were LSWs or held a related degree, and CSSD #902, who oversaw the Social Services Department, was also not an LSW.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
