F0835

D

Deficient Administration of Consultant Services, Facility Assessment, and Staff Training

Hagerstown, Maryland Survey Completed on 01-29-2026

Penalty

Fine: $21,665

Summary

Facility leadership failed to ensure appropriate conditions and oversight for a nephrology nurse practitioner (NP) consultant who had been seeing residents since November 9, 2025. At least five residents had nephrology consultations documented starting January 21, 2026, but the completed consultation notes were not uploaded into the medical record for several days, even when they contained recommendations or concerns. The DON reported that the NP would be seeing all new admissions and all residents with kidney disease, while the medical director stated that the consultant was not to see every new admission and that a physician order and an actual nephrologist following behind the NP were required. During the survey, it was identified that there had been no contract in place during the months the NP had been seeing residents, and the contract produced by the NHA was signed only the day before, demonstrating a lack of an established, consistent process for use of this consultant.

The facility did not have an accessible, current facility-wide assessment to determine needed resources and staff competencies. When surveyors requested the facility assessment, the NHA was unable to locate it and had to request it from corporate, and she acknowledged she had not reviewed the assessment since assuming her role on August 25. As a result, the training and skill sets required for staff to care for the resident population had not been determined. Review of the orientation PowerPoint showed that required behavioral health training was not included, and personnel files for an LPN, an RN, an activity assistant, and multiple GNAs showed they were allowed to care for residents without having completed the required behavioral health training.

Further review of the facility’s training program revealed that while computer-based modules existed for required topics such as effective communication, resident rights, elder abuse, QAPI, infection control, compliance and ethics, and behavioral health, the infection control module did not include the facility’s own infection prevention and control policies and procedures. Training transcripts showed that several GNAs, an LPN, and a laundry aide had not completed required annual trainings or had significant gaps since prior years. The acting NPE stated that although a training process was in place, no one was ensuring timely completion, and these staff continued to work. Additionally, nurse aide files for multiple GNAs lacked evidence of annual performance evaluations and 12 hours of training with competencies in the last 12 months, and the nurse aide training program provided by the NHA consisted only of a list of computer-based modules without competency components. The acting NPE confirmed that the facility had not developed and implemented a nurse aide training program based on evaluations, and the NHA acknowledged there was no consistent person in the educator role.