Failure to Maintain Qualified Social Worker and Resident Rights
Summary
The facility failed to maintain a qualified full-time social worker in a 220-bed facility, resulting in a substandard level of care impacting all residents, including one specific resident in the survey sample. The deficiency was highlighted by the case of a resident who was moved against his will to a locked memory care unit, despite being cognitively intact and able to make his own decisions. The resident had requested to stay in his current room and plan for discharge, but his requests were ignored, and he was not provided with the services of a social worker to assist with care and discharge planning. The resident, who had no diagnosis of dementia, was moved to the memory care unit due to an alleged elopement risk, although he had never eloped and had only gone outside once to sit in the sun. The facility staff failed to honor the resident's autonomy and did not involve a social worker in the decision-making process. The resident expressed dissatisfaction with the conditions in the memory care unit, citing a lack of personal items, activities, and basic amenities, which contributed to his distress. The facility had been without a social worker from late June until mid-November, and the newly hired social worker was not adequately qualified according to state and federal regulations. The facility lacked policies or procedural guidance for moving residents to the memory care unit, and there was no evidence of physician involvement in the decision to move the resident. The deficiency was further compounded by the lack of social work services during the resident's stay, leading to the withholding of the resident's rights and involuntary seclusion.
Penalty
Resources
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The facility did not employ a qualified full-time social worker despite having more than 120 beds, leaving the position vacant for several months after the prior social worker resigned. Review of the staff roster showed no social worker, and HR confirmed there was no full- or part-time social worker during that period. An RN acting as interim ADON reported attending care plan meetings without anyone assigned to perform social work duties. A part-time LSW later stated that before his start, no one was maintaining social work responsibilities and that he was addressing uncompleted reports and residents’ discharge needs once he began.
The facility did not maintain a qualified full-time SW despite being licensed for 180 beds, as required by CMS guidelines and state regulations. The LNHA and HRD reported that the full-time SW position had been vacant for several months, with only a part-time or per diem SW providing limited hours before also leaving shortly before the survey. Timecard records showed very low SW hours over multiple pay periods, confirming the lack of full-time coverage. The facility’s own SW job description emphasized responsibility for ensuring residents’ medically related emotional and social needs were met, highlighting the significance of the vacancy.
The facility did not comply with its own policy requiring a full-time social worker and went extended periods without a qualified social worker on staff. Over multiple months within a 9‑month review period, no qualified social worker was employed, and an unqualified staff member who originally worked as a concierge was informally assigned to handle social work responsibilities despite lacking a social work degree or training. The Administrator confirmed these gaps in qualified social work coverage.
The facility failed to ensure social services were provided by a qualified full-time social worker in a building with more than 120 beds. The SSD hired for the role held a bachelor’s degree in criminal justice rather than in a qualifying social work field and relied only on informal, as-needed consultation with a social worker at another facility, without regular supervision. The NHA acknowledged he had assumed the SSD had appropriate consultation and confirmed there was no facility policy defining the required qualifications for the social worker position.
The facility did not maintain a qualified full-time social worker position after both prior social workers left their employment in late December, leaving the facility without full-time social services coverage. Residents reported that there had been no full-time social worker since the end of the year, and one resident stated she needed social services for a legal matter. The current social worker reported she started in early January, had only worked a few full days, and was not full-time at the time of the survey, resulting in noncompliance with state social services requirements.
Surveyors found that the facility did not employ a qualified full-time social worker as required for a facility with more than 120 beds. The job description for the Social Services Director (SSD) required at least a bachelor’s degree in social work or another human services field plus one year of supervised social work experience in a health care setting. Review of the SSD’s file showed only a high school diploma and prior SSD experience in another nursing facility, and in an interview the SSD confirmed this was the highest level of education despite serving in the full-time SSD role for over two years.
Failure to Maintain Required Full-Time Social Worker Coverage
Penalty
Summary
The facility failed to employ a qualified full-time social worker despite having a licensed capacity of 130 beds, exceeding the 120-bed threshold that requires a full-time social worker. Review of the SSA Facility Summary Report showed the facility’s licensed capacity and license expiration date, and review of the staff roster provided on 3/17/2026 revealed no staff member with the position title of social worker. Human Resources reported that the last full-time social worker resigned in mid-December 2025 and that there was no social worker on a full- or part-time basis from that time until 3/16/2026. During this period without a social worker, RN A, who had been acting as interim ADON, stated she attended care plan meetings but that no one had been assigned to perform the social worker duties in those meetings. A licensed social worker interviewed on 3/18/2026 reported he began working part-time on 3/16/2026 and confirmed that prior to that date no one was maintaining the social worker’s responsibilities, and he was then working on uncompleted reports and residents’ discharge needs. He stated that not having a social worker could result in residents’ discharge needs not being met or unidentified admission, discharge, or social barriers affecting their care. The interim Administrator confirmed he had just started on 3/16/2026 and that the facility only had a part-time social worker at that time.
Failure to Maintain Required Full-Time Social Worker Coverage in a Large Facility
Penalty
Summary
The facility failed to employ a qualified full-time Social Worker (SW) despite being licensed for 180 beds, which exceeds the 120-bed threshold requiring a full-time SW under CMS guidelines implemented on 11/28/17 and N.J.A.C. 8:39-39.3(a); 39.2. During the survey entrance conference, the Licensed Nursing Home Administrator (LNHA) stated that the facility did not have a full-time SW and that the part-time SW had left approximately two weeks earlier. The Human Resources Director (HRD) later confirmed that the facility had no full-time SW for the last five months and that, after the full-time SW left, a part-time or per diem SW worked up to 30 hours per week before also leaving two weeks prior to the survey. The LNHA reviewed a Director of Social Work job posting dated 08/16/2024 with the surveyor and stated that it was around that time the facility lost its full-time SW, acknowledging that the facility should have a full-time SW to meet residents' needs. Timecard records for the SW showed minimal hours worked in successive pay periods from mid-November 2025 through late January 2026, with hours ranging from 4.25 to 8.92 per pay period, demonstrating that social work coverage was far below full-time. The facility’s own SW job description specified that the position’s primary purpose was to assist in planning, organizing, and developing the Social Services Department to ensure that residents’ medically related emotional and social needs were met on an individual basis, underscoring the gap created by the absence of a full-time SW.
Failure to Employ a Qualified Full-Time Social Worker
Penalty
Summary
The facility failed to employ a qualified full-time social worker as required by its own policy and federal regulations for a facility with more than 120 beds. The facility’s undated Social Services guidelines stated that a social worker would be employed on a full-time basis, yet a facility document signed by the Administrator on 2/12/2026 showed that from 5/9/2025 to 5/27/2025, 6/10/2025 to 8/11/2025, 10/8/2025 to 11/26/2025, and from 1/5/2026 to 2/12/2026, the facility did not employ a qualified social worker, totaling approximately 167 days (5.5 months) out of 9 months reviewed. During an interview, the individual currently functioning in the social worker role stated they began employment in October as a concierge and served in that role until early January, after which they were acting as the social worker despite having no social work degree or training and only “helping out with the social worker stuff” until a social worker could be hired. In a separate interview, the Administrator confirmed the periods during which the facility did not have a qualified social worker employed.
Unqualified Social Services Director Without Defined Qualification Policy
Penalty
Summary
The facility failed to ensure that social services were provided by a qualified full-time social worker in a facility with more than 120 beds. The Social Services Director (SSD), interviewed on 2/4/26, reported she began working in the role in October 2025 and confirmed that her bachelor’s degree was in criminal justice, not in a qualifying social work field. She stated that when she had questions, she reached out informally to a social worker at another facility, but she did not have any regular scheduled meetings or formal supervision with that individual. In a separate interview on 2/5/26, the Nursing Home Administrator (NHA) stated he assumed the SSD had someone she consulted with from her hire date to the present, but he did not verify this. He further acknowledged that the facility did not have a policy outlining the required qualifications for the social worker position, contributing to the hiring of an SSD who did not meet the regulatory educational requirements.
Failure to Maintain a Full-Time Social Worker Position
Penalty
Summary
The facility failed to employ a qualified full-time social worker despite having more than 120 beds. During an interview, Resident 1 reported that there had not been a full-time social worker since the end of the previous year, and in a resident group interview, another resident similarly stated that there had been no full-time social worker since December 2025. At that same group interview, a resident reported needing social services related to a legal matter. Review of employee files showed that one of the facility’s two social workers left on December 23, 2025, and the other left on December 31, 2025. The current social worker stated that she began working on January 7, 2026, had only worked four full days since starting, and was not employed full-time at the time of the interview. These findings demonstrate that the facility did not have a full-time social worker in place during the period reviewed, in violation of 28 Pa. Code: 201.14(a) and 211.16(a).
Unqualified Social Services Director Employed in Large Facility
Penalty
Summary
The facility failed to employ a qualified full-time social worker as required for a facility with more than 120 beds, affecting the provision of medically related social services for 196 residents. The facility’s job description for the Social Services Director (SSD) specified that any facility with more than 120 beds must employ a qualified social worker on a full-time basis and that the social services department must be directed by a qualified professional social worker with at least a bachelor’s degree in social work or another human services field, such as sociology, gerontology, special education, rehabilitation counseling, or psychology, plus one year of supervised social work experience in a health care setting. Review of the SSD’s personnel file showed that the SSD’s highest level of education was a high school diploma, with no documentation of a bachelor’s degree in social work or a related human services field, although the SSD had prior SSD experience in another nursing facility. In an interview, the SSD confirmed she had been working full-time in the role for two and a half years and verified that her highest educational attainment was a high school diploma. The Administrator and Nursing Consultant were informed of and acknowledged these findings.
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