South Jersey Extended Care

Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to store utensils in a clean, dry location; not exposed to splash, dust, or other contaminations, and failed to keep utensils covered or inverted to maintain sanitation in a safe, consistent manner. This deficient practice was evidenced by the following:On 11/19/25 at 10:30 AM, the surveyor, in the presence of the Food Service Director (FSD), observed in the facility kitchen, a white bin labeled Flour, with a clear top. Inside of the container, the surveyor noted a white powder and a clear plastic scoop utensil resting within the powder. When asked whether the scoop utensil was normally kept within the product, the FSD responded no, they should not be left in the flour, they should be cleaned and placed in the drying area after use for sanitary reasons. [...]

Inspectors wroteBased on interview, review of the facility's policy, and other pertinent facility documents, it was determined that the facility failed to implement their abuse policy to complete reference checks on employees before their start date. The deficient practice was identified for 6 of 107 employees (Employee #1, Employee #2, Employee #3, Employee #4, Employee #5, and Employee #6), reviewed and was evidenced by the following:On 11/19/25 at 10:24 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) the personnel files of all the new employees who were hired since the last standard survey (6/19/2024), whether currently employed or terminated, for review by the survey team. A review of the employee personnel files revealed the following: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain a safe, comfortable, and home-like environment for a.) residents who required the use of a wheelchair (Resident #5, #15, #29, #37, #50, #52, #and #56) and b.) a resident who required the use of an over the toilet commode (Resident #5). This deficient practice was identified on 2 of 2 units, A/B Unit and C/D Unit, and was evidenced the following:On 11/19/2025 at 11:33 AM, the surveyor observed Resident #74 in the hallway, seated in a wheelchair on a seat cushion. The seat cushion had a large amount of residue buildup on the sides and a rip along the right lateral side of the cushion. The wheelchair contained a large amount of thick residue on the seat and the frame. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete the Comprehensive Minimum Data Set (MDS), a periodic and federally mandated standardized assessment tool, within the required time frame. This deficient practice was identified for 1 of 10 residents (Resident #6) reviewed for Resident Assessment and was evidenced by the following: Reference: The Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual classified the Observation (Look Back) Period as the time period over which the resident's condition or status was to be captured by the MDS. The Assessment Reference Date (ARD) referred to the last day of the observation (or look back) period that the assessment covered for the resident. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete the Quarterly Minimum Data Set (MDS), a periodic and federally mandated standardized assessment tool, within the required timeframe. This deficient practice was identified for 4 of 10 residents (Resident #5, #12, #18, and #35) reviewed for Resident Assessment and was evidenced by the following:Reference: The Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual classified the Observation (Look Back) Period as the time period over which the resident's condition or status was to be captured by the MDS. The Assessment Reference Date (ARD) referred to the last day of the observation (or look back) period that the assessment covered for the resident. The Quarterly assessment was considered timely if 1). [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to transmit a Minimum Data Set (MDS) in accordance with federal guidelines. This deficient practice was identified for 4 of 10 residents reviewed for resident assessment (Resident #2, #4, #8 and #11). This deficient practice was evidenced by: The MDS is a comprehensive federal mandated process for clinical assessment of all residents that must be completed and submitted to the Quality Measure System. The facility must electronically transmit the MDS no later than 14 days of assessment completion. After transmitting the MDS a quality measure is generated to enable a facility to monitor a resident's decline and progress. The following residents were identified as having late assessment completions: 1. Resident #2: the Quarterly MDS was completed on 9/15/25 and was transmitted and accepted on 11/19/25.2. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: accurately account for and document the administration of controlled medications. This deficient practice was identified on 1 of 2 medication carts reviewed for medication storage, and was evidenced by the following:During medication storage review on 11/21/25 at 11:10 AM, the surveyor in the presence of the Licensed Practical Nurse (LPN #1), reviewed the C/D unit long hall nursing unit's medication cart's which revealed the following: the individual resident Controlled Drug Record log (declining inventory log) for Resident #29 indicated the 9:00 AM (9 AM) dose of pregabalin (a controlled medication used to treat pain) 100 milligram (mg) tablet was not signed out on the declining inventory log. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to a). remove unwanted medication from the resident's bedside table (Resident #27), and b). properly secure medication within the medication cart for 1 of 2 nurses observed during the medication administration pass. This deficient practice was evidenced by the following: 1.) On 11/20/2025 at 8:16 AM, the surveyor observed Licensed Practical Nurse (LPN) #2 prepare medications for Resident #27, which included polyethylene glycol 3350 powder (used to treat constipation) 17 grams mixed with eight (8) ounces of water, and fluticasone-salmeterol 250-50 micrograms/actuation (MCG/ACT) aerosol powder inhaler (used to treat chronic obstructive pulmonary disease). LPN #2 then locked the medication cart and took the medications into the resident's room. [...]

Inspectors wroteBased on interview and review of facility documents, it was determined that the facility failed to ensure that a Certified Nursing Assistant (CNA) received at least 12 hours of mandatory in-service training annually for 1 of 5 CNAs reviewed (CNA #1). The deficient practice was evidenced by the following:On 11/24/25, at 11:00 AM, the surveyor reviewed the provided in-service education for five (5) randomly selected CNAs for the years 2024 and 2025, which revealed the following: CNA #1, with a date of hire of 6/30/15, had 9.25 hours of in-service training from date of hire anniversary dates (June 2024 - June 2025). On 11/25/25 at 10:00 AM, the surveyor interviewed the Director of Nursing (DON), in the presence of the Licensed Nursing Home Administrator (LNHA) and the survey team. [...]

Inspectors wroteBased on interview and document review it was determined that the facility failed to ensure a Surety Bond was in place to provide coverage to protect resident personal needs account funds held by the facility. The deficient practice effected all residents who had personal needs funds held by the facility and was evidence by the following: On 06/13/24 at 2:00 PM. and again on 06/14/24 at 9:00 AM, the surveyor requested a facility Surety Bond from the Liscensed Nursing Home Administrator (LNHA). On 06/14/24 at 9:30 AM, the LNHA provided a Funds Balance Report for 06/03/24 which listed 48 active residents with a combined balance of $20,829.05. The surveyor again requested a Surety Bond from the LNHA. On 06/14/24 at 12:20 PM, the LNHA provided a Commercial Crime Policy effective: July 24, 2023- July 24, 2024, for a Bond Limit: $90,000. [...]

Inspectors wroteBased on interview and review of Nursing Staffing Report sheets, Payroll Based Journal (PBJ) Reports and facility provided documents, it was determined that the facility failed to ensure the Director of Nursing served as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents for 7 of 16 days reviewed The deficient practice was evidenced by the following: A review of the Nurse Staffing Reports completed by the facility for 05/07/2023 through 05/13/2023 revealed the facility had one RN for the day shift on 05/12/2023. On 05/12/2023, the census was 100 residents. A review of the Nurse Staffing Reports completed by the facility for 05/26/2024 through 06/01/2024 revealed the facility had one RN for the day shift on 05/26/2024 and 05/27/2024. On 05/26/2024, the census was 92 residents. On 05/27/2024, the census was was 91 residents. [...]

Inspectors wroteBased on interview and review of facility documents, it was determined that the facility failed to provide Certified Nurse Aides (CNA) regular in-service education based on the outcome of employee job performance appraisals. The deficient practice was identified for 3 of 10 CNAs reviewed. The deficient practice was evidenced by the following: A review of the facility provided documents titled, Employee Job Performance Appraisals revealed eleven measurable attributes such as but not limited to, Job Expectations, Adaptability, Leadership, and Dependability. Each attribute also has a comments section and a goal section. Each attribute can be scored with a numeral revealing the following: [...]

Inspectors wroteBased on observation, interviews, and other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe consistent manner. This deficient practice was evidenced by: On 06/13/24 between 09:24 AM until 10:01 AM, the surveyor observed the following in the kitchen in the presence of the Dietary Manager (DM): 1. On 06/13/24 at 9:25 AM, the surveyor observed a Dietary Aid (DA) preparing food during the initial tour of the kitchen and was noted not wearing a beard guard. The DM stated that all staff have been trained according to the policy and procedure of the kitchen to wear proper attire while working in the kitchen. He confirmed that all staff must wear a hairnet and beard guard to prevent food contamination. The DA left the workstation and walked towards the entrance to put on his beard guard. 2. [...]

Inspectors wroteBased on observation, interview and document review it was determined that the Licensed Nursing Home Administrator failed to ensure that facility policies and procedures were developed and consistently implemented. This failure to ensure a system was in place for residents who smoked independently and held their own smoking material and lighter, had the potential to effect all residents on 3 of 3 resident units and was evidenced by the following: On 06/13/24 at 2:03 PM, three surveyors observed a person walking behind the building on a path by the woods. The surveyors approached the person, who was by him/herself, to interview them, while the person was headed toward the road and then turned toward the parking lot. The person identified him/herself as Resident #25 and stated that he/she lived at the facility. [...]

Inspectors wroteBased on interview and review of pertinent facility documents it was determined that the facility failed to submit accurate No RN [Registered Nurse] Hours Payroll Based Journal (PBJ) Report to the Centers of Medicare and Medicaid Services (CMS). The deficient practice was identified for 4 of 7 infraction dates on the PBJ Report for Fiscal Year Quarter 2 January 1 - March 31. A review of the PBJ Report for Fiscal Year Quarter 2 2024 January 1 - March 31 revealed the following days as ,Infraction Date under the No RN Hours Metric: 01/27 01/28 02/24 02/25 03/10 03/23 03/24 A review of the facility provided document titled, The Following RN rotation coverage revealed that on 01/27/2024 and 01/28/2024, the facility's current Director of Nursing worked as an RN. At that time, the DON was not promoted to the DON role. [...]

Inspectors wroteBased on observation, interview and document review it was determined that the facility failed to ensure a resident room and the resident environment was free of insects, and that staff addressed a resident in a dignified manner. This deficient practice occurred for 1 of 20 residents reviewed (Resident #55) and was evidenced by the following: On 06/13/24 at 10:28 AM, Surveyor #1 observed Resident #55 in bed and there was a noticeable urine odor in the room and the resident's urinary catheter was lying on the bed. Resident #55 stated, he/she was waiting for coffee at that time and acknowledged there was an odor. Black flies were noted scattered throughout the room and when asked the resident about the flies, the resident confirmed he/she was aware of the flies. Resident #55 then stated the smell isn't from me. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure Resident #12 preferences had been accommodated. This deficient practice occurred for 1 of 20 residents reviewed (Resident #12) for accommodation of needs and was evidenced by the following: During the initial tour on 6/14/24 at 10:31 AM, interview with Resident #12 revealed that would like to get out of the bed at a certain time and their wishes had not been honored. On 6/17/24 at 10:14 AM surveyor #2 followed up with Resident #12 regarding their concerns. The observation of Resident #12 revealed that Resident #12 was in bed dressed in a hospital gown. Resident #12 was upset and was crying to the surveyor and stated that he/she had not been able to contact their family. Resident #12 further stated that their belongings were still at the other facility and could not get in touch with the Social Worker (SW). [...]

Inspectors wroteBased on observation, interview and document review it was determined that the facility failed to ensure the smoking policy was followed to ensure the safety for residents who smoked and held their own cigarettes and lighters. This deficient practice occurred for 2 of 2 residents who held their own lighters (Resident #22 and #25) and was evidenced by the following: a. During the initial tour on 6/13/2024 at 09:49 AM, the surveyor observed Resident #22 in their room. Upon inquiry, Resident #22 informed the surveyor that he/she was a smoker. On 06/17/2024 at 10:38 AM, the surveyor observed Resident #22 in the designated smoking area and was smoking. On 06/18/2024 at 09:00 AM, the surveyor observed Resident #22 in their room. Resident #22 informed the surveyor that they held their own cigarettes and lighter. [...]

Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to maintain a resident bathroom toilet (Resident room [ROOM NUMBER]) in a sanitary working condition for four days and was evidenced by the following: On 06/13/2024 at 9:58 AM, during initial tour of the facility, the surveyor observed the toilet in Resident room [ROOM NUMBER]. The toilet bowl was observed with brown debris and paper products in the bowl. There was no water observed in the toilet. The resident stated that the toilet does not work, and the facility was aware the toilet had been broken for a few days. On 06/13/2024 at 12:59 PM, the surveyor reviewed the unit maintenance log sheets. The toilet in Resident room [ROOM NUMBER] was not on the log sheets to be repaired since 5/24/24. [...]

Inspectors wroteBased on observation and interview it was determined that the facility failed to maintain all resident rooms and common areas in a clean and sanitary manner. The deficient practice occurred on 1 of 3 units and in the Sub-Acute smoking courtyard and was evidenced by the following: On 6/13/24 at 10:41 AM, two surveyors toured the Sub-Acute smoking courtyard and observed cigarette butts were located throughout the lawn area surrounding the gazebo, on top of a garbage can and partially filling the inside of an open bucket that rested on the ground which included empty cigarette packages. There were signs posted to utilize cigarette disposal not the ground. On 06/17/24 at 9:39 AM, the surveyor observed Resident #47 in bed and observed the privacy curtain was stained in several areas, there was soiled areas on several walls and a broken window blind with flies in the room. [...]

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to conduct a new Preadmission Screening and Resident Review (PASARR) level II assessment after a resident was newly diagnosed with a mental illness. This deficient practice was identified in 1 of 2 residents reviewed for Preadmission Screening and Resident Review PASARR (Resident #44) and was evidenced by the following: Resident #44 was a resident of the facility. On 06/13/2024 at 11:43 AM the surveyor reviewed the Level I PASARR (a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) for Resident #44 dated 12/21/17 which was negative, meaning the resident did not have any mental illness diagnoses that could lead to a chronic disability. The surveyor reviewed the quarterly Minimum Data Set (MDS), an assessment tool dated 10/4/2023. [...]

Inspectors wroteBased on observation, interview, review of records, and review of pertinent documents, it was determined that the facility failed to provide appropriate incontinence care, and personal hygiene care for 1 of 2 residents. (Resident #12) reviewed for activities of daily living. The deficient practice was evidenced by the following: On 06/17/24 at 9:24 AM, the surveyor observed Resident #12 in bed. Resident #12 was alert and stated that incontinence care was not provided in a timely manner. When asked to elaborate, Resident #12 stated he/she was assisted with incontinence care at 11:00 PM and again this morning at 3:00 AM. Upon inquiry, the resident stated that he/she had not received care yet. The resident further stated that he/she was soiled and would like to be changed. The surveyor left the room and informed the Licensed Practical Nurse/Unit Manager. [...]

Inspectors wroteBased on interview, record review, and pertinent facility documentation it was determined that the facility failed to identify conflicting physician's orders for emergency treatment on the medical record for 1 of 1 resident reviewed for cardio-pulmonary resuscitation (a medical procedure involving repeated compressions of a person's chest, performed in an attempt to restore blood flow to and breathing of a person whose heart stopped), resident #49. This deficient practice was evidenced by: A review of Resident #49's Order Summary Report in the Electronic Medical Record (EMR) revealed that, resident #49 had a full code order with a start date of 05/02/2024, and a DNR/DNI (do not resuscitate/do not intubate (to insert a tube into a person's throat, to help with breathing) order with a start date of 01/29/2024. [...]

Inspectors wroteBased on interview and document review it was determined that the facility failed to ensure that a system was in place and followed to review and notify physicians of laboratory values. This deficient practice occurred for 1 of 20 residents reviewed (Resident #47) and was evidenced by the following: On 06/17/24 at 9:39 AM, observed resident in bed and respond pretty good I guess when asked how was doing. A review of the electronic medical record revealed resident was discharged to the hospital and admitted for six days, and a discharge summary from the hospital, revealed the discharge diagnoses that included acute kidney injury, altered mental status, dehydration, hypernatremia (elevated blood sodium levels), Diabetes Type 2 and Urinary Tract Infection. A Nutrition Note dated: 06/12/24, timed 17:15 [5:15 PM] that was completed by the Registered Dietitian, revealed: Assessment and Plans: [...]

Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to obtain a Physician's Order (PO) for an orthotic device for 1 of 1 resident (Resident#14) reviewed for positioning and mobility. On 06/13/2024 at 10:04 AM, the surveyor observed Resident #14 in the bed. An orthotic device was observed near Resident #14's right elbow. According to the admission Record, Resident #14 was admitted to the facility with a diagnosis including but not limited to; multiple sclerosis (a chronic disease of the central nervous system), cerebral infarction (a stroke) and hemiplegia (paralysis). [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to follow the physician orders related to the use of continuous oxygen (O2) for 1 of 1 resident (Resident #42) reviewed for the use of oxygen. This deficient practice was evidenced by the following: On 06/13/2024 at 9:44 AM, the surveyor observed a staff member assisting Resident #42 via a recliner chair, into the common area of the facility. The surveyor observed Resident #42 was wearing a nasal cannula attached to a portable O2 tank and the amount was set at 2 liters per minute (lpm) of oxygen. On 06/14/2024 at 8:43 AM, the surveyor observed the resident's privacy curtain drawn around the bed and could hear a staff member assisting the resident. At that time, the surveyor observed the resident's recliner chair in the hallway. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to a.) appropriately don (put on) Personal Protective Equipment (PPE), and b.) store respiratory equipment to prevent contamination and exposure to the environment. This deficient practice was evidenced by the following: On 06/13/2024 at 9:44 AM, the surveyor observed a staff member assisting Resident #42 via a recliner chair, into the common area of the facility. The surveyor observed Resident #42 was wearing a nasal cannula attached to a portable O2 tank and the amount was set at 2 liters per minute (lpm). On 06/14/2024 at 8:43 AM, the surveyor observed Resident #42's portable O2 tank was on the back of the recliner chair in the hallway. The surveyor observed that there was tubing with the nasal cannula wrapped around the tank. [...]

Inspectors wroteComplaint # NJ 00167157 Based on interview and rerecords review, it was determined that the facility failed to address Resident #194's (Activities of Daily Living ) ADLs care needs by ensuring that the resident was independent with care prior to discharge. The facility did not have a care plan that addressed discharge. The facility discharged Resident #194 without addressing and acknowledging family members voiced concerns of the resident being unable to independently care for himself/herself. This deficient practice was identified for 1 of 2 residents reviewed for discharge and was evidenced by the following: On 6/17/24 at 10:30 AM, the surveyor reviewed Resident #194's closed medical record. Resident #194 was admitted to the facility on [DATE] and discharged on 6/30/23. Resident #194's diagnoses included but were not limited to; [...]

Inspectors wroteComplaint # NJ 00167157 Based on interviews, record review and review of pertinent documentation provided by the facility, it was determined that the facility failed to ensure that the resident call system was maintained in operable condition as evidenced by the following: 1. On [DATE] at 11:30 AM, the surveyor entered a random resident's room and asked the resident to activate the call light in the room. The surveyor went into the hallway and observed that the light was flashing and an audible sound could be heard. During an interview with the residents, they indicated that the call light was working but staff would take time to answer the call light. One of the resident revealed that 30 minutes could elapsed before staff would answer the call light. The surveyor reviewed the Maintenance logs and observed on 2 of the 4 units the following entries: Unit CD: [...]

Inspectors wroteBased on observations, interviews, and other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe, consistent manner. This deficient practice was evidenced by: On 03/20/23 from 9:40 AM to 10:34 AM, the surveyor observed the following in the kitchen in the presence of the Dietary Director (DD): 1. The surveyor observed the [NAME] who wore gloves as he prepared cooked pork to be served during lunch that day. The [NAME] then doffed (removed) his gloves and failed to perform hand hygiene prior to taking the surveyor on a tour of the kitchen. 2. In the walk-in refrigerator: a. On the top shelf of a four-tiered rack, there was an eight-pound container of potato salad that was marked with a use by date of 04/02/23 and failed to contain an opened date. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation it was identified that the facility failed to provide residents with a clean, home like environment. This deficient practice was identified on one of three nursing units, (the AB unit) and for two (2) of 21 resident's, (Resident #45 and Resident #48) reviewed for environment and was evidenced by the following: 1.) On 03/20/23 at 10:23 AM, the surveyor observed Resident #48 laying in bed in his/her room. The surveyor further observed a Tube Feeding (TF) pole in the resident's room. The bottom of the TF pole had caked, tan material imbedded on it. The surveyor saw that the resident's beige colored privacy curtain was pushed back towards the wall by the head of the resident's bed and had a large brown, circular stain on it. [...]

Inspectors wroteBased on observation, interview, review of medical records and other facility documentation, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS- an assessment tool utilized to facilitate the management of care) for 2 of 21 residents reviewed (Residents #45 and #65). This deficient practice was evidenced by the following: 1. On 3/20/23 at 11:03 AM, the surveyor observed Resident #45 seated in his/her room eating breakfast. According to the Medical Record, Resident #45 was admitted with a diagnosis that included schizophrenia (a mental illness.) The surveyor reviewed the Pre-admission Screening and Resident Review (PASRR) Level I and Level II for Resident # 45. It reflected that the resident had a serious mental illness. The surveyor reviewed Resident #45's Significant Change in Status MDS dated [DATE]. [...]

Inspectors wroteBased on observation, interview, review of medical records, and review of other pertinent facility documentation, it was determined that the facility failed to provide necessary services, consistent with professional standards of clinical practice by not a.) performing neurological checks (neuro-checks, an assessment of an individual's neurological functions, motor and sensory response, and level of consciousness) for a resident that fell and hit their head and b.) following facility policy and procedures. This deficient practice was identified for 1 of 4 residents (Resident # 28) reviewed for accidents and was evidenced by the following: Reference: New Jersey Statutes, Title 45, Chapter 11, Nursing Board, The Nurse Practice Act for the state of New Jersey states; [...]

Inspectors wroteBased on observation, interview, review of medical records, and review of other pertinent facility documentation it was determined that the facility failed to a.) conduct a complete and thorough fall investigation and b.) update and implement fall prevention interventions on a resident's Care Plan (CP). This deficient practice was identified for 1 of 4 residents (Resident #28) reviewed for accidents and was evidenced by the following: According to Resident #28's admission Face Sheet, Resident #28 was admitted to the facility with diagnoses that included but was not limited to obstructive pulmonary disease, schizophrenia, dementia, and seizure disorder. The Annual Minimum Data Set (MDS-an assessment tool utilized to facilitate the management of care) dated 10/26/22, indicated that the resident had severe cognitive impairment and severe impairment with decision making. [...]

Inspectors wroteBased on observation, interview, and review of pertinent documents, it was determined that the facility failed to ensure residents received the food on the meal ticket and adhered to resident preferences. This deficient practice was identified for 1 of 1 resident (Resident # 38) reviewed for food preferences and accuracy of meal tickets and was evidenced by the following: On 3/20/23 at 10:16 AM, the surveyor observed Resident #38 lying in bed resting. According to the Medical Record, Resident #38 was admitted to the facility with diagnoses which included, but not limited to: End Stage Renal Disease (ESRD) and Hyperkalemia (high Potassium in the bloodstream). [...]

Inspectors wroteBased on interview and review of documentation, it was determined that the facility failed to employ a Social Worker (SW) with the required one year of supervised social work experience in a healthcare setting working directly with the individuals per the facility's job description and Centers for Medicare and Medicaid Services (CMS). This deficient practice was identified for 1 of 1 SW employed and was evidenced by the following: On 03/22/23 at 10:16 AM, the surveyor interviewed the SW who stated that she worked in the facility for eight (8) months and that she was the only SW in the facility and did not have a SW degree. The SW stated that her degree was a Bachelors Degree in Behavioral Science and stated, I did this (job) for people with disabilities before. On 03/24/23 at 11:00 AM, during a follow up interview with the SW, the surveyor inquired about the SW's job orientation. [...]