Health inspection·January 10, 2024

F 0839 Employ staff that are licensed, certified, or registered in accordance with state laws. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable State laws for 1 of 3 staff (Staff A) reviewed for staff qualifications. Residents Affected - Some The facility failed to ensure Staff A completed the appropriate educational requirements of a bachelor's degree in social work and was appropriately licensed to practice social work in the State of Texas. This failure could place residents at risk of not receiving care and services from staff who were properly trained and supervised. The findings included: Record review of Staff A's personnel file revealed a handwritten Application for Employment dated 5/23/2014 with position desired marked as marketing/SS (Social Services) with a job history listed as working at different nursing home facility with the job title of Social Services with duties of all aspects of social services-MDS's discharges, admits and so-on. Staff A listed her educational background as not graduated from a local community college. The application was signed by Staff A. Record review of Staff A's personnel file revealed a New Hire Form which indicated Staff A was hired on 5/26/2014 with the job title of Marketing/Social Worker on a full-time basis and was signed by Staff A on 5/23/2014 and an unknown manager on the same date. Record review of Staff A's personnel file revealed Staff A signed a job description titled Director of Social Services dated 11/07/2016 which indicated the educational requirements included a bachelor's degree from an approve(d) school of social work and must be registered as an ACSW (Academy of Certified Social Workers-social worker accreditation), must be a member in good standing in the National Association of Social Workers and Academy of Certified Social Workers, Inc., and have experience which was left blank and not filled in. The job description read The primary purpose of your job position is to plan, organize, develop, and direct the overall operation of the Social Service Department in accordance with current federal, state and local standards, guidelines and regulations, our established policies and procedures, and as may be directed by the Administrator, to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis. The Administrator signature on the job titled was left blank. During an observation on 1/10/2024 at 4:43 p.m., Staff A's name badge was observed to read Social Services. Page 1 of 3 675766 675766 01/10/2024 The Courtyard Rehabilitation and Healthcare Center 3401 E Airline Dr Victoria, TX 77901

F 0839 Level of Harm - Minimal harm or potential for actual harm During an interview on 1/08/2024 at 3:08 p.m., the HR Director stated the facility Social Worker was not an actual Social Worker. She stated Staff A was a community and resident liaison and their marketer and admissions person supervised by ED B who worked for the corporation. The HR Director stated the Administrator was aware Staff A was not a licensed Social Worker and had worked at the facility for a while. The HR Director stated the facility was not hiring a Social Worker. Residents Affected - Some During an interview on 1/10/2024 at 4:44 p.m., Staff A stated she had worked at the facility for 11 years and her title was Social Service Designee. She stated Social Service Designee meant that the facility had less than 120 beds. She stated she completed assessments including MDS assessments, advocated for the residents, discharges, referred to community resources and in-house resources, and made appointments. Staff A stated she did not have a college degree but had taken some college classes. Staff A stated her work was supervised by Executive Director B (ED B) who was a licensed Social Worker. Staff A stated she communicated with ED B via telephone, texting, and emails. She stated she communicated with ED B when she had a question about her work which she estimated to be 4-5 times a month. She stated there was no specific time/date/schedule for the reviews. Staff A stated ED B reviewed MDS assessments, UDS (assessments), and kept an eye on everything she did. She stated the ED B did not co-sign her MDS assessments or review them with her. Staff A stated ED B could review her work at her discretion. Staff A stated she signed her own MDS assessments as Social Services Manager. Staff A stated when signing documents in the computerized medical records of the residents she signed her name, and the computer auto generated the title Social Services Manager. She stated if she would not typically sign her name in that manner. She stated her title should be Social Service Designee. Staff A stated she did not know who was responsible for assigned the title of Social Services Manager to her. During an interview on 1/10/2024 at 5:37 p.m., ED B stated she worked was an Administrator for a nursing facility in another city owned by the same corporation. ED B stated in addition to working as a LNFA (Licensed Nursing Facility Administrator) she was also a licensed Social Worker (LMSW). ED B stated she provided oversight to Staff A as a SSD (Social Services Designee). She stated she used to go to the facility one time a month, then switched to once a quarter. ED B stated she was also available for questions if Staff A called her. ED B stated as part of the oversight, she conducted a seminar once every 6 months. ED B stated she did not review Staff A's progress notes or sign off on them. ED B stated as part of the oversight she went through MDS assessments, discharge assessments and guided Staff A with forms but did not sign off on them. ED B stated in 2/2023 she discussed some documentation involving discharge planning issues with Staff A. ED B stated the last time she reviewed Staff A's work was 4/15/2023 and the last time she was in the facility was May 2023. ED B stated Staff A did not attend the seminar on 8/08/2023 that she conducted. ED B stated to her knowledge the facility was not required to have a licensed social worker because they only had 58 beds and they could have a SSD instead but Staff A had to work under a licensed Social Worker. ED B stated Staff A should be signing documents with SSD and not Social Services Manager. ED B stated she was not aware Staff A was using the title of Social Services Manager. ED B stated if the signature was auto populated it would be okay because it was not like Staff A was saying she was licensed. During an interview on 1/11/2024 at 10:23 a.m., the Administrator stated she was aware that Staff A was not a licensed Social Worker. The Administrator stated her expectation for Staff A were for her to consult with her if there was something she did not understand about her job duties. She stated she also expected Staff A to reach out and be under the supervision of a licensed Social Worker. The Administrator stated she herself was not a licensed Social Worker. She stated Staff A should be under the supervision of ED B. The Administrator stated supervision requirements meant ED B should meet with Staff A 675766 Page 2 of 3 675766 01/10/2024 The Courtyard Rehabilitation and Healthcare Center 3401 E Airline Dr Victoria, TX 77901

F 0839 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some continuously and actively look at resident changes, social services dynamics and assist with additional guidance. The Administrator stated continuously meant ongoing support as need and face-to face visits. She stated the face-to-face visits should occur quarterly. The Administrator stated the pandemic had changed a lot of things and visits could be conducted via a tele-visit. The Administrator stated she was Staff A's direct supervisor. The Administrator stated she supervised Staff A by meeting with her 1-2 times a month and using the conversation to gauge Staff A's needs. She stated she also communicated with ED B to see if there was anything she (Administrator) needed to go over with Staff A. The Administrator stated she last spoke with ED B before surveyor intervention in December 2023. She stated at that time she (Administrator) told ED B they did not have any needs at the time. The Administrator stated Staff A's title was what was listed on the employee roster. She confirmed the roster stated Staff A was the Social Services Manager. The Administrator stated she had reviewed Staff A's personnel file but was not aware that Staff A had a signed job title which indicated she needed to be a licensed Social Worker or the need for a bachelor's degree. The Administrator stated Staff A was hired prior to her (Administrator) coming to the facility. She stated she had worked at the facility since May 2022. The Administrator stated the facility did not have a contract with a licensed Social Worker. Record review of a Facility Assessment last revised June 2023 revealed: Page 14-15, Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies. 3.1: Social Work Staff: Total Number Needed-1, Total Number Employed in Position at time of Assessment-1, Plan to Hire Additional staff if needed-0.5. Record review of a facility job description titled Social Services Manager not signed by any parties and undated revealed: Qualifications: Education and/or Experience: Must have, as a minimum, a bachelor's degree in social work or a bachelor's degree in a human services field including but not limited to sociology, special education, rehabilitation counseling and psychology. Must have, as a minimum, 5 years of experience as a Social Worker, preferably in a hospital, long-term care facility, or other related health care facility. Record review of a facility policy titled Social Services, Provision of Medically Related last revised 12/2023 revealed: It is the policy of this facility to provide medically related social services to attain or maintain the highest practicable physical, mental, or psychosocial well-being of each resident. 675766 Page 3 of 3