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F0725
F

Deficiency in Weekend Nursing Staff Coverage

Shelton, Connecticut Survey Completed on 05-19-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide the appropriate number of nursing staff on weekends during Quarter 1 and Quarter 2 of Fiscal Year 2024, as evidenced by Payroll Based Journal (PBJ) submissions that triggered for excessively low weekend staffing. Interviews revealed that the Scheduler was not responsible for PBJ submissions and was unaware of the low staffing trigger, while the HR coordinator, who is currently responsible for PBJ submissions, was not employed at the facility during the period in question. The Scheduler reported that weekend staffing was a challenge due to frequent call-outs by nursing and agency staff, as well as issues with staff retention. The VP of Clinical Operations confirmed awareness of the low weekend staffing during the specified quarters. The facility's policy manual requires complete and accurate electronic submission of direct care staffing information to CMS, and notes that noncompliance may result in enforcement actions. The deficiency was identified through review of PBJ data and staff interviews, which confirmed that the facility did not meet required weekend staffing levels during the specified timeframe.

See complete original report
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