Facility Lacks Qualified Social Worker
Summary
The facility did not have a qualified Social Worker, which had the potential to affect all 69 residents residing in the facility. The Social Services Director (SSD) and Social Services Coordinator (SSC) did not have degrees in social work or a related human services field and did not have one year of supervised social work experience in a health care setting. The Facility Assessment indicated the facility is licensed for 125 beds with an average daily census between 50-65 residents over the last 6 months and stated the facility provides a social worker, mental health social worker/counseling services to its residents. The SSD was hired on 2/14/24 as a full-time employee with a degree in Health Care Administration and previous work experience in behavioral intervention and working with adolescents with autism. The SSD confirmed they were not certified as a Social Worker in the State of Wisconsin and did not have one year of supervised social work experience in a health care setting. The SSC was hired in August of 2023 as a Certified Nursing Assistant (CNA) and started in the Social Services Department in December of 2023 while pursuing a biomedical degree. The SSC confirmed they were not certified as a Social Worker in the State of Wisconsin, did not have a degree in social work or human services, and did not have one year of supervised social work experience in a health care setting. The Nursing Home Administrator confirmed the facility's previous Social Worker left in January of 2024 and was certified with the State of Wisconsin.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to employ a full-time licensed SW was identified in a facility with 188 beds. The SSD reported she had a social work degree and prior NY licensure but was not licensed in TX and was working toward reciprocity while performing SW duties remotely for the facility. The VP of HR was unfamiliar with TX licensure rules, and the ADMN stated he expected a licensed full-time SW but no other SW was in the building to provide services.
The facility, licensed for 131 beds and housing 75 residents, did not employ a qualified full-time social worker as required for facilities with more than 120 beds. The individual serving as the Social Services Designee reported not being licensed or certified as a social worker and lacking a related degree, having only prior experience working with a social worker in another facility. The NHA confirmed both the facility’s bed capacity and that the designee was not a qualified social worker, while also acknowledging awareness of the regulatory requirement for a full-time qualified social worker in a facility of this size.
Surveyors found that the facility, licensed for more than 120 Medicare/Medicaid beds, did not employ a full-time qualified LSW as required. Personnel records showed that the person functioning in the social services role had been hired as a CNA and later promoted to social services but did not hold a social work license. In an interview, the Administrator confirmed both the regulatory requirement for a full-time LSW and that no LSW was employed at the facility.
A facility licensed for 157 beds failed to employ a qualified full-time social worker over several months, despite regulatory requirements for facilities with more than 120 beds. Review of the facility summary and staff roster confirmed there was no social worker on staff, and there was no specific policy for a social worker, only a general acknowledgment that one was required. The QA Director reported that the prior social worker left and that she had been performing social services duties since then, believing this met the requirement as she had a similar degree, even though she did not hold the social worker title. The ADM and Director of Special Projects acknowledged the need for a social worker to address residents' psychosocial and related service needs, such as podiatry, dental, and vision, while asserting that resident care had not been negatively affected because the QA Director was covering these functions.
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.
Unqualified Full-Time Social Worker: The facility failed to verify that the full-time SSD met the required education and licensure qualifications. Review of the SSD’s personnel file showed no bachelor’s degree in social work or similar human services field, and the Administrator reported that requested MSW, transcripts, and social worker license were never provided during the survey.
Failure to Employ a Full-Time Licensed Social Worker
Penalty
Summary
The facility failed to employ a qualified social worker on a full-time basis in a building with a licensed capacity of 188 resident beds. During interview, the SSD stated she had a master's degree in social work from Puerto Rico and had been licensed in New York, but she was not licensed in Texas at the time of the survey and was working to obtain reciprocity. She stated she had been performing social work duties for the facility since December 2025, but she did not come to the facility and all communication was by phone or virtually. During interviews, the VP of HR stated she was unfamiliar with Texas regulations for a social worker and needed to review them before answering questions about licensure requirements. The ADMN stated his expectation was to have a full-time social worker that was licensed, but the SSD was still working on transferring her license to Texas. He stated no other social worker was in the building to perform social work duties, although the SSD had corporate oversight. Record review showed the Social Services job description dated 12/12/2025 listed licensure as preferred, the Social Services Director job posting listed licensure as required, and the facility policy stated not all medically-related social services are provided by a qualified social worker, but the facility is responsible for ensuring residents receive these services.
Lack of Qualified Full-Time Social Worker in a Large-Bed Facility
Penalty
Summary
The facility failed to employ a qualified full-time social worker despite being licensed for 131 beds, which is more than the 120-bed threshold requiring such a position. During an interview, the Social Services Designee (SSD-G) reported having started work at the facility in June 2025 and confirmed serving as the facility’s Social Services Designee. SSD-G acknowledged not being certified or licensed as a social worker and not having a degree in a related field, stating only prior experience working in another facility alongside a social worker. In a separate interview, the Nursing Home Administrator (NHA-A) confirmed the facility’s licensed bed capacity of 131 and acknowledged that SSD-G was not a licensed or certified social worker, while also stating awareness that a facility with more than 120 beds requires a full-time qualified social worker. This practice had the potential to affect all 75 residents residing in the facility. No additional resident-specific medical histories or conditions were described in the report beyond the statement that all 75 residents in the facility had the potential to be affected by the lack of a qualified social worker.
Failure to Employ Required Full-Time Licensed Social Worker
Penalty
Summary
The facility failed to employ a full-time qualified Licensed Social Worker (LSW) despite being licensed for 126 Medicare/Medicaid beds and having a census of 119 residents, which required a full-time LSW. Review of personnel records showed that the individual serving in the social services role, identified as Social Service Worker (SSW) #175, was originally hired as a Certified Nursing Assistant (CNA) on 02/26/25 and later promoted to the SSW position on 10/27/25. Further review of this employee’s file confirmed that she did not hold a social work license. During an interview on 04/08/2026 at 3:23 P.M., the Administrator acknowledged that the facility was required to have a full-time qualified LSW and confirmed that SSW #175 was not licensed as a social worker and that the facility did not have any LSW employed at the time of the survey.
Failure to Employ Required Full-Time Social Worker for 157-Bed Facility
Penalty
Summary
The facility, licensed for 157 beds, failed to employ a qualified full-time social worker from January 2026 to April 2026, despite the regulatory requirement for a full-time social worker in facilities with more than 120 beds. Review of the Facility Summary Report confirmed the licensed capacity of 157 beds, and review of the undated staff roster showed there was no social worker employed at the facility during this period. The facility also did not have a policy specific to a social worker, although leadership acknowledged it was a general requirement to have one. During interviews, the Quality Assurance Director stated that the previous social worker had left around November 2025 and that she had been performing social services for residents since that time. She believed that as long as someone with a similar degree was performing social services, the facility met the requirement for having a social worker, even if that person did not use the title of social worker. The ADM and Director of Special Projects acknowledged that a social worker was needed for the number of beds in the facility and that it was important to have a social worker to meet residents' needs, including arranging podiatry, dental, and vision services. They stated there was no negative effect on resident care because the Quality Assurance Director was performing social worker duties after the prior social worker left, and they reported they were attempting to contact the former social worker and were actively seeking to hire a replacement.
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.
Unqualified Full-Time Social Worker
Penalty
Summary
The facility failed to ensure that the full-time social worker was qualified and failed to verify that educational requirements were met in a facility licensed for 180 beds. During review of the Social Services Director’s personnel record, it was found that she did not have a bachelor’s degree in social work or a similar human services field. In an interview, the Administrator stated that she had concerns about the SSD’s performance and, after the SSD was promoted, requested copies of her master’s degree in social work, transcripts, and social worker license, but these documents were never provided. The Administrator also reported that during the recertification survey she asked the SSD to go home and obtain her degree and credentials, and by the end of the survey the SSD had not returned to the facility or contacted her.
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