Inaccurate PBJ Reporting of Licensed Nursing Coverage
Summary
The facility did not ensure accurate reporting of the mandatory submission of staffing information based on payroll data to the Centers for Medicare & Medicaid Services (CMS). This issue has the potential to affect all 11 residents residing within the facility. The facility failed to enter accurate data in their Payroll Based Journal (PBJ) reporting, which triggered deficiencies for five fiscal year quarters due to the failure to have licensed nursing coverage 24 hours a day. The facility's policy on PBJ reporting involves pro-rating staff hours based on the number of beds and workload, which led to discrepancies in the reported data. The CMS PBJ Staffing Data Reports for fiscal year quarters 3 and 4 of 2023 and quarter 1 of 2024 indicated multiple days with less than 24 hours of licensed nursing coverage. Specific dates and the reported licensed nursing hours were provided, showing significant shortfalls on several days. Interviews with the Business Office Manager (BOM), Director of Nursing (DON), Payroll Coordinator, Rehabilitation Specialist, and Social Worker confirmed that there is always a licensed nurse on the unit, but the reported data did not reflect this due to the pro-rating method used. The BOM indicated that she uses an equation to divide the licensed nursing hours among the different licensed entities within the home, which results in the reported hours not accurately representing the actual coverage. The DON and other staff members confirmed that the unit is never left without a licensed nurse, but the data reported to CMS does not accurately reflect the 24-hour coverage due to the pro-rating of hours. This discrepancy in reporting has led to the facility being flagged for not having licensed nursing coverage 24 hours a day, despite the actual presence of licensed staff on the unit at all times.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Incomplete and Inaccurate PBJ Staffing Submission: The facility failed to submit complete and accurate PBJ staffing data based on payroll and other auditable records. CMS PBJ reports showed excessively low weekend nurse staffing across multiple FY quarters, while review of weekend nursing schedules and working hours showed adequate staffing. An admin staff member stated the administrator and corporate staff were responsible for PBJ submission, and the facility policy required PBJ data to be submitted in a uniform format to CMS.
The facility failed to consistently include the daily census on nurse staff postings and had PBJ staffing data that triggered survey review for low weekend staffing and LNs available 24 hours per day. Although posted schedules showed licensed nursing coverage 24/7, the staffing coordinator said they only entered agency staff, and the administrator stated corporate submitted PBJ, contract/agency staff may not have been entered, and nurse manager hours may have been coded incorrectly when worked on the floor.
Incomplete PBJ staffing reporting led to a trigger for excessively low weekend staffing. CMS PBJ data for FY 2026 Q1 and Q2 showed low weekend staffing, but review of nursing schedules showed adequate staffing on duty. An Administrative Nurse stated the Administrator submitted the PBJ nursing information and that weekends were always staffed well, including with agency staff when needed. The facility’s PBJ policy required reporting payroll data for employees, agency, and contract staff.
Inaccurate PBJ staffing submission: The facility failed to electronically submit complete and accurate direct care staffing data to CMS through PBJ. Review of the PBJ Staffing Data Report showed excessively low weekend staffing for multiple quarters, but the nursing schedule and payroll data did not reflect lower weekend staffing than weekdays. An admin staff member stated corporate changed the PBJ report to code admin nurses' weekend hours as direct care, even though staffing levels were the same on weekends and weekdays.
Failure to submit PBJ staffing data. Review of staffing data reports showed the facility did not submit direct care staffing information for Quarter 2, and an interview with Administer E1 confirmed there was no further documented evidence of submission.
The facility failed to submit complete and accurate PBJ staffing data to CMS for Q4. Review of the PBJ discrepancy report showed the payroll system underreported total nursing hours by 1,606.80 hours because extra break time was deducted and one employee lacked a CMS job title code, so those hours were not counted. The Administrator stated the software did not correctly carry over LPN and CNA hours and that accurate coding would have met the 3.4 HPRD and produced correct census and staffing hours.
Incomplete and Inaccurate PBJ Staffing Submission
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information through Payroll Based Journaling (PBJ) based on payroll and other verifiable and auditable data. CMS PBJ reports for FY Quarter 1, Quarter 2, Quarter 3, and Quarter 4 indicated excessively low weekend nurse staffing, but review of the facility’s weekend nursing schedules and working hours for those quarters showed the facility had adequate staffing. During interview on 08/18/25 at 08:26 AM, Administrative Staff A stated the administrator and corporate staff were responsible for submitting the PBJ. The facility’s PBJ policy, revised 10/2025, stated the facility would submit PBJ data in a uniform format to CMS, including staffing community, agency, and contract staff.
Incomplete PBJ Staffing Reporting and Daily Census Posting
Penalty
Summary
The facility failed to consistently include the facility census on the daily nurse staff posting. Survey review of the Payroll Based Journal (PBJ) staffing data showed the facility was triggered for review for low weekend staffing and for licensed nurses available 24 hours per day during the 1st quarter of 2026 on several weekend dates, and for licensed nurses available 24 hours per day during the 2nd quarter of 2026 on several weekend dates. The deficiency affected all 60 current residents, their families, and visitors. Review of the facility’s staff postings and actual working schedules for Quarter 1 and Quarter 2 showed licensed nursing staff were present 24 hours per day, 7 days per week, and the review did not identify weekends that were excessively low for staffing. During interview, the staffing coordinator stated they were only responsible for entering agency staff information and were not sure why the facility triggered on PBJ. The administrator stated corporate submitted the PBJ, was not sure whether contract or agency staff had been entered, and said PBJ submission was an area for improvement because it had not been submitted appropriately. The administrator also stated there was a high probability that nurse manager hours were not coded correctly when they worked the floor as floor nurses. A facility policy regarding PBJ reporting was requested but not provided.
Incomplete PBJ Staffing Reporting
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information through the Payroll-Based Journal (PBJ) using payroll and other verifiable and auditable data, which resulted in a trigger for excessively low weekend staffing. CMS PBJ data for FY 2026 Q1 and Q2 showed excessively low weekend staffing, while review of the facility’s nursing staffing schedules for those quarters showed adequate staffing on duty. During interview, the Administrative Nurse stated the Administrator submitted the nursing information for the PBJ report and said the facility was always staffed well on weekends, with agency staff assisting when needed. The facility’s PBJ policy dated 10/2025 stated the community would submit payroll data in a uniform format to CMS, including staffing information for community, agency, and contract staff, and that it distinguished employees from agency and contract staff when reporting direct care staffing information.
Inaccurate PBJ Staffing Submission
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS through Payroll-Based Journal (PBJ) reporting. Based on interview and record review, the facility did not accurately submit hourly staffing data for all nursing personnel, and the PBJ Staffing Data Report showed excessively low weekend staffing for Q4 of FY 2025 and Q1 and Q2 of FY 2026. Review of the nursing schedule and payroll data sheets for the cited time periods did not show discernibly excessively low weekend staffing compared with weekday staffing. On 07/28/2026, Administrative Staff A stated that the corporate office made changes to the PBJ report to code administrative nurses' hours as direct care when they worked weekends, and that the facility had the same staffing levels on weekends as during the week. The facility's PBJ policy stated that the community would submit payroll data in a uniform format to CMS, including staffing information for community, agency, and contract staff, and that direct care staff are those with direct interpersonal contact with residents.
Failure to Submit PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS in the Payroll-Based Journal system based on payroll and other verifiable and auditable data. Review of the facility’s staffing data reports showed that no PBJ data were submitted for Quarter 2, covering January 1, 2026 through March 31, 2026. An interview with Administer E1 on July 23, 206 at 02:00 p.m. confirmed there was no further documented evidence of submission.
Incomplete and inaccurate PBJ staffing submission
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to CMS for Q4 PBJ reporting. Review of the June 2022 CMS Long-Term Care Facility PBJ Policy Manual showed that facilities are required to electronically submit direct care staffing information based on payroll and other auditable data, including direct care staff, job categories, resident census data, and direct care staff turnover and tenure by the required deadline. Review of the facility’s October 2025 through December 2025 HPRD discrepancy report showed the total nursing hours reported by the payroll system were inaccurate by 1,606.80 hours. The discrepancy was attributed to extra break times being deducted from employee hours and to one employee who did not have a CMS job title code, causing those hours not to be counted. During interview, the Administrator stated the payroll software did not correctly carry over licensed nurse and CNA total hours and that, if the codes had carried over correctly, the facility would have met the 3.4 HPRD and would have reported correct census and staffing hours.
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