SSD Qualifications Not Verified
Summary
The facility failed to ensure the Social Services Director (SSD) met the qualifications required for a social worker in a facility with more than 120 resident beds. The SSD was hired by the facility on 8/15/2025 as Medical Records Director and later had a Personnel Action/Change Form dated 9/15/2025 showing a title change from Medical Records Director to SSD and a department change to Social Services. The SSD’s employee file contained a Bachelor of Science degree in Elementary Education and a Certificate of Completion for Social Service Designee dated 12/2/2024, but it did not contain documented evidence that she had at least one year of supervised social work experience in a healthcare setting and working directly with individuals before starting in the SSD role. The SSD stated during interview that she had received 45 hours of Social Services Designee training and that she had a certification for counseling for 180 hours supervised by a social worker, but neither she nor the facility could provide documented evidence of that experience. She also stated she had held social services positions at prior facilities with 56 and 99 beds and had covered for the SSD when the Social Services Designee was gone, which she considered her experience as SSD. The Administrator stated the SSD was initially hired as MRD, later considered for the SSD position, and that the facility did not have her complete a new application or sign a job description for the SSD role, although the signed job description should have been in the employee file.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Employ a Qualified Full-Time Social Worker: The facility, certified for 226 beds, went for about three months without a qualified SW while the former SSD had left and the new SSD was still in training. Other staff without the required SW qualifications helped with social services tasks, and during this period a resident received a defective discharge notice that lacked sufficient support for the stated discharge reason and did not include accurate appeal information.
A facility with 182 residents failed to have a qualified full-time social service director. The SSD stated she was in her first year of a bachelor's degree program and did not have another bachelor's degree in a related field, while the Administrator confirmed the degree was not completed and the facility's census was 175-180 residents on average. The reviewed job description and policy did not align with current regulatory requirements for the position.
Licensed Social Worker Not Working Full Time: A facility with over 120 beds failed to ensure a licensed social worker worked full time in the building. Record review showed the last full-time licensed social worker day was months earlier, while SSDs were performing day-to-day duties, including care conferences, discharge planning, MDS assessments, and admission assessments. The Administrator could not provide set in-building times for the Senior SW, who stated they were usually present only three to five times per week.
The facility failed to have a full-time qualified social worker in a building with 123 licensed beds. The SSD stated she did not meet the qualifications for a Social Worker for facilities over 120 beds, and the qualified Regional SSD was only in the facility a couple of times per month. The Facility Assessment identified Social Services as needed to support residents with cognitive impairment, mental health dxs, and behaviors.
A facility licensed for 187 beds failed to maintain a qualified full-time social worker after the licensed social worker resigned. The Administrator stated that an unlicensed social worker was hired to assist and remained listed as the social worker while the facility interviewed applicants for a licensed replacement. The Social Services policy described the social worker role as including discharge planning, psychosocial coordination, and interdisciplinary communication.
Failure to Employ a Qualified Full-Time SW: The facility did not have a full-time qualified SW after the SW was suspended and later terminated, leaving only a Social Worker Assistant who was not licensed and did not meet federal qualification requirements. The Assistant handled discharge planning, progress notes, notices, and referrals without SW oversight, while many residents had MH diagnoses and some had SUD diagnoses.
Failure to Employ a Qualified Full-Time Social Worker
Penalty
Summary
The facility failed to employ a qualified full-time social worker in a building certified for 226 beds. Review of the facility’s social worker job description showed that a qualified social services worker needed at least a bachelor’s degree in social work or another human services field and one year of supervised social work experience in a health care setting working directly with individuals. Employment records showed that from 03/13/2026 through 06/18/2026, the facility did not have a qualified social services worker. Interviews confirmed that the former Social Services Director left in March 2026, the current Social Services Director was hired in June 2026 and was still in training, and the facility’s Customer Service Liaison and Director of Rehabilitation Services were helping with social services tasks even though they did not meet the minimum qualifications for a social worker. The Regional Director of Operations and the Administrator both confirmed that the facility went for about three months without a qualified social services worker while the owner was recruiting and advertising for the position. The Owner stated that recruiters and sign-on bonuses were used in an effort to fill the role, but a qualified applicant was not obtained until the new social services director was hired the prior month. During the same period, the facility issued Resident 1 a discharge notice dated 05/15/2026, and review of the record found insufficient evidence supporting the stated discharge reason and that the notice did not provide accurate information needed to appeal the planned discharge.
Unqualified Social Service Director
Penalty
Summary
The facility failed to have a qualified full-time social service director for a facility with 182 residents. On interview, the Social Services Director stated she had been in the position for two weeks, was in her first year of a bachelor's degree program, had 1 year and 3 months of prior experience as a social service designee at the same facility, and did not have another bachelor's degree in a related field. The Administrator stated the requirement for the social services director was a minimum of a bachelor's degree and 1 year of experience in social services, and confirmed the current Social Service Director's bachelor's degree was not completed. The facility's Social Service Director job description listed responsibilities for overseeing the Social Service Department, but the reviewed policy did not align with current regulatory requirements for the position.
Licensed Social Worker Not Working Full Time
Penalty
Summary
The facility failed to ensure a licensed social worker worked full time in the building for a facility with more than 120 beds, affecting 127 residents. Record review showed that the last day a licensed social worker worked full time in the facility was 02/10/26. During interviews, the Social Service Designee stated she had been working at the facility since 05/14/26 and was scheduled to test for her social work license on 07/20/26, while the senior social worker with a licensed independent social work license had been overseeing work product. The Administrator stated they could not provide specific times the Senior Social Worker was scheduled to be in the building and that they came as needed. The Senior Social Worker stated they oversaw the Social Service Designees, were available when needed, and were usually in the building three to five times a week, while the designees performed the day-to-day job duties. Another Social Service Designee stated they had been in the role for about a week and had previously completed care conferences, discharge planning, MDS assessments, admission assessments, and discharge planning.
Failure to Maintain a Qualified Full-Time Social Worker
Penalty
Summary
The facility failed to have a full-time qualified social worker in a building with 123 licensed beds. The Facility Assessment, revised 6/19/26, identified Social Services as part of the staffing and resources needed to provide competent support and care for residents, including residents with cognitive impairment, mental health diagnoses, and behaviors. During the survey, the Social Services Director stated that she was the facility's SSD but was currently enrolled in courses to obtain a bachelor's degree and did not meet the qualifications for a Social Worker for facilities with over 120 beds. The Regional SSD was reported to have a degree and meet the qualifications, but was only in the facility a couple of times per month and not full time. The facility's Midnight Census Report documented 62 residents.
Unlicensed Social Worker Used in Place of 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 187 beds, and during interview and record review on 07/02/26 at 5:25 p.m., the Administrator stated that the employee list showed Social Worker R as an unlicensed social worker. He said he hired Social Worker R on 04/03/26, when the person was unlicensed, to assist the previously licensed social worker who had resigned on 05/30/26. The Administrator said he was interviewing applicants to hire a licensed social worker as soon as possible. The facility’s Social Services policy stated that the social worker role includes discharge planning to ensure safe transitions of care, regulatory compliance, and coordination with residents, families, and the interdisciplinary team.
Failure to Employ a Qualified Full-Time Social Worker
Penalty
Summary
The facility failed to employ a full-time qualified Social Worker in a building licensed for 123 beds that admitted residents with psychosocial care needs related to mental illness, substance use disorder, and behavioral issues. The facility’s policy stated that all residents should receive necessary behavioral health services and that Social Services should serve as the contact person for behavioral services. Review of the census showed 99 occupied beds, and review of the resident analyzer report showed that 5 residents had substance use disorder diagnoses and 81 residents had one or more mental health diagnoses. Social Worker #1 was suspended on 05/28/26 during an abuse investigation and her employment was terminated on 06/03/26. After that, the facility had only a Social Worker Assistant, who worked full-time but was not licensed and did not have a bachelor’s degree in an acceptable field, so she did not meet the qualifications of a full-time qualified social worker. The Social Worker Assistant stated she had been the only social service staff member since the departure of SW #1, had no oversight from a social worker, and the facility had no contract with outside social service providers. The Administrator confirmed that the facility had not employed a full-time qualified social worker since 05/28/26 and had no outside agreement to provide social services during the vacancy.
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