Inconsistent Weekend Staffing in Facility
Summary
The facility did not ensure consistent staffing on weekends to meet the needs of the 30 residents residing in the facility. During the review of the payroll-based journal (PBJ) staffing data for the first quarter of the federal fiscal year 2023, the facility was flagged for excessively low weekend staffing. The facility's assessment indicated that the average daily census was between 28 to 32 residents, requiring 5 licensed nurses and 8 certified nursing assistants (CNAs) to provide direct care. The staffing requirements included having one registered nurse (RN) or licensed practical nurse (LPN) per shift, with specific ratios for day, PM, and night shifts. However, the facility's PBJ data revealed a discrepancy in staffing levels, particularly on weekends. The Director of Nursing (DON) stated that the facility's staffing needs are determined by the census and acuity of residents, using a scheduling program called Smart Linx. Despite the program's algorithm creating an ideal schedule, the facility was still triggered for low weekend staffing. The Regional Vice President (VP) acknowledged that the facility was automatically down 16 hours on weekends due to the absence of certain staff roles, such as the Minimum Data Set (MDS) nurse and Social Services. Additionally, a systemic issue was identified where agency staff hours were not being accurately pulled into the PBJ reporting, affecting the reported weekend staffing hours. This issue was attributed to a checkbox in Smart Linx not being checked, which led to agency hours not being integrated into the system, impacting the facility's staffing data.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Inaccurate PBJ Staffing Data Submission: The facility failed to submit complete and accurate direct care staffing data to CMS for a quarter of PBJ reporting. The PBJ report showed an excessively low weekend staffing trigger, and the ADM stated she compiled the data, sent it to corporate, and a third-party company submitted it to CMS, while also acknowledging she did not know why the low weekend staffing was triggered.
Failure to Submit Required Payroll Base Journal Staffing Data: The facility failed to electronically submit complete and accurate direct care staffing data to CMS for Q2 2026, including payroll and other verifiable auditable data for agency and contract staff. The CASPER report showed the required PBJ data was not submitted, and the Administrator said the omission was due to a transition in HR personnel. The HR Director stated she did not know why the PBJ was not submitted, and the facility policy assigned submission responsibility to the HR Director or designee.
Failure to Submit PBJ Staffing Data: The facility failed to submit PBJ direct care staffing data to CMS for a quarter after corporate payroll staff believed a TPV had submitted it. The CPC stated the omission was not discovered until later, he did not check the CASPER report because he did not know he could access it, and the ADM stated the facility had no policy or procedure for PBJ submission.
The facility failed to submit complete and accurate PBJ staffing data to CMS for a quarterly reporting period. HR, the DON, and the ADMIN described a process where staffing hours were gathered from invoices, adjusted, entered into Workday, and then pulled by the Home Office service center for CMS submission. Record review showed the submission failed because one employee did not match after a software change, creating a fatal coding error in the file, and the issue was not discovered until after the deadline had passed.
Inaccurate PBJ Staffing Submission: The facility failed to submit complete and accurate direct care staffing information through PBJ. CMS data for FY 2026 Q2 showed excessive low weekend staffing, but staffing sheets showed the same number of direct care staff worked on weekends and weekdays. Administrative Staff A confirmed the facility did not have low weekend staffing and stated the DON, ADON, and MDS Nurse worked weekends as needed.
Failure to Submit Quarterly PBJ Staffing Data: The facility failed to submit complete and accurate PBJ staffing data to CMS for one quarter. Record review showed no staffing submission for the quarter, and the Quality Director stated the prior coordinator had said she was submitting the data, but the facility later learned it had not been submitted and that she no longer worked at the facility.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS based on payroll and other verifiable and auditable data for the quarter of 01/01/2026 through 03/31/2026. The PBJ report for that quarter documented a staffing data concern for excessively low weekend staffing, and the report stated that this metric was triggered because the submitted weekend staffing data was excessively low. During an interview on 06/25/2026, the Administrator stated she was responsible for submitting staffing data to CMS, did not know why the low weekend staffing was triggered for the second quarter of 2026, and explained that she compiled the data, sent it to corporate, and a third-party company submitted it to CMS. She also stated that if incorrect data was submitted, CMS would not have accurate information concerning staffing.
Failure to Submit Required Payroll Base Journal Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS, including payroll and other verifiable and auditable data for agency and contract staff, for the second quarter of 2026. Record review of the CMS Payroll Base Journal Staffing Data Report (CASPER Report 1705D, Fiscal Year Quarter 2-2026) showed that the facility did not submit the required data for January 1 through March 31, 2026. During interview, the Administrator stated he had been at the facility since 2018 and said the Payroll Base Journal for the second quarter of 2026 was not submitted because of a transition in human resource personnel. He stated human resources was responsible for submitting the Payroll Base Journal. The Human Resource Director, who said she had worked at the facility for three weeks, stated she did not know why the Payroll Base Journal was not submitted and confirmed that human resources was responsible for ensuring it was completed. Record review of the facility policy titled Payroll Base Journal-Staffing, revised in August 2023, stated that the Human Resource Director or designee was responsible for submitting the Payroll Base Journal according to the CMS schedule.
Failure to Submit PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS through the Payroll Based Journal (PBJ) for the first quarter, covering 10/1/2025 through 12/31/2025. A review of the CMS PBJ Staffing Data Report dated 6/16/2026 showed that the facility did not submit staffing data for that quarter. During an interview on 6/24/2026, the Corporate Payroll Consultant stated the facility's corporate payroll staff used a third-party vendor to submit PBJ data and believed the data for the first quarter had been submitted to the vendor, but later discovered in March 2026 that it had not been submitted to CMS. The Corporate Payroll Consultant also stated he did not check the CASPER Report because he did not know he could access it. The Administrator stated he was aware the first quarter PBJ had not been submitted after speaking with the Corporate Payroll Consultant, and stated the facility did not have any policy and procedure for PBJ submission.
PBJ Staffing Data Not Submitted
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for FY Quarter 1 2026, including agency and contract staff, using payroll and other verifiable and auditable data in the required uniform format. Review of the CMS PBJ report showed the facility did not submit staffing data for the quarter. The report identified that the submission failure was tied to the facility’s PBJ reporting process and the quarter ending December 31, 2025. During interviews, HR stated staffing hours were gathered from invoices, adjusted through time adjustment forms, entered into the Workday payroll tracking system, and then pulled by the Home Office service center for submission to CMS. The DON gave a similar account, stating nursing hour reports were received from HR, verified, entered into Workday, and then submitted by the service center. The ADMIN also stated that nursing hours were compiled through HR and DON review, entered into Workday, and submitted by the service center. The ADMIN said the report would be pulled to determine whether any nursing hours were missing. Record review of the facility’s internal investigation showed the PBJ data was submitted by the facility payroll vendor, but CMS loaded a report showing a failed submission. The investigation stated that one employee did not match due to new software that went live on 1/1/26, causing a fatal error. The facility identified a coding error attached to employee positions in the file, and the contracted service did not discover the issue until after the submission deadline had passed. CMS later denied the facility’s appeal to resubmit the PBJ data. The ADMIN stated the facility did not have a PBJ policy other than following CMS guidelines, and the CMS policy manual required quarterly direct care staffing and census data to be timely and accurate.
Inaccurate PBJ Staffing Submission
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information through the Payroll-Based Journal (PBJ) system based on payroll and other verifiable and auditable data. The CMS PBJ Staffing Data Report for FY 2026 Quarter 2 showed excessive low weekend staffing, but review of the facility staffing sheets showed the same number of direct care staff worked on weekends and weekdays. During interview, Administrative Staff A verified the facility did not have low weekend staffing and stated that the DON, ADON, and MDS Nurse worked on weekends as needed. The facility policy titled Reporting Direct Care Staffing Information (Payroll Based Journal), revised August 2022, stated that direct care staffing information was reported electronically to CMS through the PBJ system.
Failure to Submit Quarterly PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS no less frequently than quarterly based on payroll and other verifiable and auditable data. Record review of the PBJ Staffing Data Report for Quarter 2 of 2026, generated on 6/17/26, showed that the facility did not submit staffing data for that quarter. During an interview on 6/17/26 at 5:30 pm, the Quality Director stated that the coordinator was responsible for submitting staffing data to CMS and that the previous coordinator had told the facility she was submitting the data, but the facility later discovered that she had not submitted it and she no longer worked at the facility.
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