Failure to Report and Follow Up on Allegation of Mistreatment
Summary
The facility failed to ensure that a resident was seen by social services within three days following an allegation of mistreatment, as per the facility's practice. Additionally, the facility did not report the allegation of mistreatment to the appropriate state agency. The resident involved, who was admitted with diagnoses including hypothyroidism, hyperlipidemia, hypertension, osteoarthritis, and a history of stroke, reported that a nurse aide roughly handled them during a transfer, resulting in bruising on the resident's hand. The incident occurred when the resident, who required assistance with mobility and self-care, rang the call bell for help to use the bathroom. The nurse aide allegedly grabbed the resident's hand and feet to transfer them to a wheelchair, which the resident claimed led to bruising. The resident did not report the incident immediately due to fear of retaliation, and it was only brought to attention after a physical therapist noticed the bruising and reported it to the nursing staff. Interviews with facility staff revealed that the social worker was aware of the incident but did not follow up with the resident within the required timeframe. Furthermore, the social worker did not report the incident to the state agency, citing workload as a reason. The facility's investigation could not substantiate the abuse, but the care plan was updated to require two staff members for assistance with the resident's care.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to employ a qualified full-time social worker: The facility, licensed for 120 beds, did not maintain a licensed social worker on a full-time basis after the prior social worker’s last day. The new social worker had a master’s degree and was scheduled to take the LMSW exam, but was not yet licensed. He was responsible for discharge planning, social services assessments, care plans, and grievances, and the Administrator stated she was unaware he could not serve in the role before passing the exam.
Failure to employ a qualified full-time social worker. Review of the employee file showed a BS degree and a Certified Therapeutic Recreation Specialist certificate, with coursework in Recreational Therapy. The NHA stated these credentials qualified the employee for the social worker role and did not confirm that the employee lacked the required bachelor’s degree in social work or a human services field.
Failure to Employ Required Full-Time LSW: The facility did not have a full-time LSW even though its census exceeded 120 residents. The SSD was not a licensed social worker and confirmed the facility had been without a full-time LSW for some time. The Administrator stated two part-time social workers from other facilities were covering duties, but they did not meet the 40-hour requirement, and the SSD job description did not specify that a social work license was required.
Failure to Employ a Full-Time Social Worker: A facility with 170 licensed beds did not have a full-time qualified social worker after the prior social worker left, and the staff roster showed no social worker employed. The ADM and ADON confirmed only a part-time social worker was available, while the ADM stated other staff, including the MDS nurse, were trying to cover social work duties such as resident assessments and concerns.
A facility with more than 120 beds failed to have a full-time, qualified social services worker. Record review showed the social worker had a BS degree, but the file lacked evidence of a social work degree or one year of supervised social work experience under a qualified social worker. The Administrator stated the individual had a human services degree with a criminal justice major and could not provide documentation of the required supervised experience; the training documents presented did not show supervised training.
Failure to employ a required full-time LSW in a facility with 151 residents. Personnel records showed the SSD was not an LSW and did not have a bachelor's degree in a human services field, and the only LSWs on record were terminated or separated from the facility. Interviews with HR, the SSD, and the Administrator confirmed the social services department had no LSW at the time of the survey, and the job description did not state the LSW requirement for a census over 120.
Failure to Employ a Qualified Full-Time Social Worker
Penalty
Summary
The facility failed to ensure that it employed a qualified social worker on a full-time basis for one of one social worker positions reviewed. The facility was licensed for 120 beds, and the census report dated 05/20/2026 showed a capacity of 120 beds with a census of 95 residents. The deficiency began when the previous licensed social worker’s last day was 05/20/2026, and the facility did not have a qualified full-time social worker in place after that date. During a telephone interview on 05/22/26, the current Social Worker J stated he was hired on 05/19/26, had a master’s degree in social services, and was scheduled to take his licensing exam on 06/06/26 for Licensed Master Social Worker. He said he was responsible for discharge planning, social services assessments, care plans, and grievances/concerns, but he was not familiar with Resident #1. The Administrator stated the facility had to have a licensed social worker full time, was not aware that Social Worker J could not work as the social worker prior to taking the licensing exam, and said the previous social worker was licensed. The Administrator did not provide the requested social worker job description prior to exit.
Failure to Employ a Qualified Full-Time Social Worker
Penalty
Summary
The facility failed to employ a full-time qualified social worker in a facility with more than 120 beds from February 16, 2026, through the present. Review of Social Worker Employee E12’s personnel file showed a Bachelor of Science degree and a Certified Therapeutic Recreation Specialist certificate, and the resume showed education that included bachelor’s degree coursework in Recreational Therapy. During an interview on 5/21/26 at 1:30 p.m., the Nursing Home Administrator stated that the Bachelor of Science degree and the Certified Therapeutic Recreation Specialist certificate qualified the employee for the social worker position. During a later interview on 5/21/26 at 1:33 p.m., the Nursing Home Administrator refused to confirm that Social Worker Employee E12 did not have at least a bachelor’s degree in social work or a bachelor’s degree in a human services field such as sociology, gerontology, special education, rehabilitation counseling, or psychology as required.
Failure to Employ Required Full-Time LSW
Penalty
Summary
The facility failed to employ a full-time Licensed Social Worker (LSW) in a building with more than 120 beds, as required by the facility assessment and the Social Services Director job description. Review of the personnel file for the Social Services Director showed she was hired on 03/16/26 and her application and resume indicated she did not have a degree in social services. During interview, the Social Services Director confirmed she was not a Licensed Social Worker and stated the facility had been without a full-time LSW for some time; she had been working at the facility since 03/16/26, and the prior full-time LSW’s last day was 02/13/26. The Administrator confirmed the facility did not currently have a full-time LSW and stated that two part-time employees from other facilities had been covering social services duties but did not meet the 40-hour requirement. The job description signed by the Social Services Director and Administrator did not state that a social work license was required when the census exceeded 120 residents.
Failure to Employ a Full-Time Social Worker
Penalty
Summary
The facility with 170 licensed beds failed to employ a qualified social worker on a full-time basis after the former social worker left the facility. Record review showed there was no social worker on the staff roster, and interviews with the ADON and ADM confirmed the facility did not have a full-time social worker, although a part-time social worker was being used in the meantime. The ADM stated the former social worker gave notice on April 15, 2026 and left on April 22, 2026, and that the part-time social worker and other staff, including the MDS nurse, were trying to catch up on social work duties such as resident assessments and addressing resident concerns. An email from the ADM indicated the facility hired a full-time social worker to start on May 18, 2026.
Unqualified Social Worker in Facility Over 120 Beds
Penalty
Summary
The facility failed to provide a full-time, qualified social services worker in a building with more than 120 beds, as required by S483.70(p). Record review for SW#1, identified by the Administrator as the facility social worker, showed a Bachelor of Science degree, but the personnel file did not contain evidence of a bachelor's degree in social work or documentation showing one year of supervised social work experience under the supervision of a qualified bachelor's degree-level social worker. During interview, the Administrator stated SW#1 had a degree in human services with a major in criminal justice and said the individual met the required qualifications because she had been in other buildings. The Administrator was unable to provide additional documentation supporting supervised social work training or experience. Later, the Administrator presented a Social Workers Department New Hire Orientation Training document and several Central Weekly SWDCP Meeting documents, but these documents did not show supervised training. The Administrator, DON, and Regional Nurse were informed of the concern, and no additional information was provided before exit.
Failure to Employ Required Full-Time LSW
Penalty
Summary
The facility failed to employ a full-time Licensed Social Worker (LSW) in a building with a census of 151 residents. Review of personnel records showed that Social Services Director #373 was hired on 03/11/25, but her application and resume did not show a degree in social services. The personnel file for LSW #360 showed he was terminated on 01/09/26, and the personnel file for LSW #451 showed she was hired on 02/12/26 and separated from the facility on 02/27/26. During interview, the Human Resources Director verified that Social Services Director #373 was the only employee in the social services department and that she was not a Licensed Social Worker and did not hold a bachelor's degree in a human services field. The Social Services Director also verified that she was not a LSW and did not have a bachelor's degree in a human services field, and stated she had been the Social Services Director since LSW #360 was fired. The Administrator confirmed the facility did not have a LSW and had not had one in the social services department since 02/27/26, stating that candidates were being interviewed but the hiring process had not been completed. Review of the undated job description for social services showed the purpose of the position was to provide services to meet residents' social and/or emotional needs, but it did not state that the Social Services Director was required to be a Licensed Social Worker when the census was over 120 residents.
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