Failure to Maintain RN Coverage
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, on ten specific days within a 91-day period. This deficiency was identified through interviews and record reviews, which revealed that the facility did not report RN hours for the specified dates. Although RN A was scheduled to work on these days, the hours were not recorded in the CMS PBJ Staffing Data Report. Interviews with the HR representative and the Director of Nursing (DON) indicated that the previous DON, who was salaried, did not clock in or out, leading to uncertainty about how her time was reported. The corporate resource nurse and the Administrator (ADM) were also unaware of the lack of RN coverage on these days. The facility's policy requires RN coverage for eight hours a day, seven days a week, to ensure resident safety and well-being. However, due to staff turnover and miscommunication at the corporate level, the facility failed to maintain this coverage. The ADM acknowledged the policy requirement and was working on a new system to track RN hours for salaried staff who do not clock in. The absence of RN coverage could potentially lead to missed assessments and a lack of leadership for the Licensed Vocational Nurse (LVN) staff, as noted by the DON.
Penalty
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Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
The facility failed to submit complete and accurate direct care staffing data to CMS via the PBJ system, resulting in reports that showed excessively low weekend staffing for multiple fiscal quarters. An administrative staff member acknowledged that a former business office manager had submitted the PBJ data incorrectly. This failure occurred despite a facility policy requiring uniform electronic submission of verifiable payroll data for all direct care staff, including agency and contract personnel, and specifying whether staff were employees or contracted workers.
The facility failed to submit accurate PBJ staffing data to CMS for one federal fiscal quarter, resulting in reported gaps in RN hours and 24-hour licensed nurse coverage despite internal records showing an RN on site at least 8 hours daily and continuous licensed nurse coverage. The ADON handled scheduling and ensured coverage but did not perform PBJ submissions, which were completed by the Controller using data exported from the staffing system, transferred to a spreadsheet, and converted for CMS upload. The Controller verified hours against payroll and only accessed CMS once per quarter to submit data and view validation messages, and neither he nor the Administrator received direct CMS alerts about problems. The Administrator first became aware of a potential issue when the facility’s staffing rating dropped, without specific information that the problem involved RN and licensed nurse coverage.
The facility failed to ensure that direct care staffing information submitted to CMS via PBJ was complete and accurate, as PBJ reports showed repeated excessively low weekend staffing and a one-star staffing rating while the facility’s own assessment documented higher daily nurse and CNA coverage. When surveyors requested detailed staffing submission data, the administrator could not promptly provide it, and a PBJ validation report showed that Total Employee Link Records were not submitted. Multiple residents reported long delays in call light response and assistance, including waits of 30–90 minutes, and one resident noted a nurse working six consecutive days due to open shifts. A CNA described working with only one other CNA in the building when others called off, and an LVN reported frequent staffing issues and difficulty finding replacements amid high turnover. The administrator stated that staffing was planned to meet state minimums, relied on a vendor to transmit timeclock data to CMS, did not personally review PBJ submissions, and was unaware of staffing triggers or low staffing star ratings, despite a policy requiring accurate daily submission of all direct care staffing, including agency and contract staff.
The facility failed to submit required payroll-based journal (PBJ) direct care staffing data to CMS for an entire fiscal quarter. A review of the PBJ Staffing Data Report showed a triggered concern for failure to submit any data for the quarter, which should have included the type, number, and hours worked for clinical staff providing resident care. In an interview, the Administrator reported that the corporate office was responsible for sending the staffing documents and acknowledged that the information was not submitted, despite being aware of the quarterly CMS reporting requirement.
The facility failed to submit complete and accurate PBJ staffing and census data to CMS for a quarterly reporting period. PBJ records showed a total census count that did not match the facility’s own monthly census records, resulting in a discrepancy of hundreds of census days. The administrator reported that PBJ and census reporting were handled at the corporate level and acknowledged prior issues with timely and accurate MDS submissions. Corporate staff later identified a different "accurate" census total after re-review, confirming that the original PBJ submission was not correct, which affected the accuracy of CMS nursing home staffing level data.
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Inaccurate PBJ Submission Resulting in Underreported Weekend Staffing
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS through the Payroll Based Journal (PBJ) system as required, resulting in reported staffing levels that did not reflect actual staffing. CMS PBJ reports for Fiscal Year 2026 Quarter 1 and Fiscal Year 2025 Quarter 3 showed excessively low weekend staffing, indicating that the data submitted did not accurately capture direct care staff hours. During an interview, an administrative staff member acknowledged awareness of a problem and reported that the previous Business Office Manager had submitted the PBJ information incorrectly. The facility’s own PBJ F851 policy required submission of payroll data in a uniform CMS-specified format for all direct care staff, including community, agency, and contract staff, and required that the data distinguish between employees and contracted or agency staff, but this policy was not followed, leading to incomplete and inaccurate staffing information being reported.
Inaccurate PBJ Submission of RN and Licensed Nurse Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS via the Payroll Based Journal (PBJ) system for one federal fiscal quarter, specifically related to RN hours and 24-hour licensed nurse coverage. Review of the PBJ data for Quarter 1 of Federal Fiscal Year 2025 showed system triggers indicating no RN hours for an extended period and no licensed nurse coverage on multiple dates. However, detailed review of the Posted Daily Nursing Staffing Forms, Daily Staffing Sheets, and nursing staff time detail reports for the same timeframe, conducted with the ADON, showed that an RN was on site for at least 8 hours every 24 hours and that licensed nurse coverage was present 24 hours a day on all of the dates in question. The Administrator reported that she first became aware of a potential PBJ issue when the facility received a 1-star staffing rating, and stated that this rating was the first indication of a problem with the Quarter 1 PBJ submissions. The ADON stated she was responsible for scheduling and staffing and ensured RN and licensed nurse coverage daily, but did not perform the final PBJ submissions. The Controller, who had been submitting PBJ data for eight years, explained that he obtained staffing information from the facility’s online staffing system after the ADON entered it, transferred it to a spreadsheet, and then uploaded it into the staffing system for conversion into a CMS-acceptable file type. He stated he verified nursing hours against payroll and logged into the CMS site only once per quarter to submit data and view validation messages, did not receive CMS alerts by email, and had not contacted CMS because he was unaware of any issue until the survey interview. The Administrator also stated she did not contact CMS after learning of the 1-star rating because she did not know the specific reason for the rating and had not received specific alert messages indicating a problem with RN and licensed nurse coverage.
Inaccurate PBJ Staffing Data Submission and Reported Delays in Resident Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure that direct care staffing information submitted to CMS through the Payroll-Based Journal (PBJ) system was complete and accurate, based on verifiable and auditable data. PBJ reports showed the facility consistently triggered for excessively low weekend staffing for three quarters and received a one-star staffing rating for two fiscal quarters. The facility assessment documented a licensed capacity of 58 residents with a current census of 50 and indicated daily nursing staffing of three nurses on day shift and two on night shift, with an RN present at least 8 consecutive hours per day and three CNAs on night shift and four on day shift. However, when surveyors requested detailed staffing submission data, the administrator stated that timeclock data went to a vendor (Xchieve) which then submitted to CMS, and that the information was located out of state and not immediately available. Review of the PBJ submitter final file validation report obtained from the facility showed that the Total Employee Link Records portion failed to be submitted. Resident and staff interviews and facility documentation further demonstrated discrepancies and concerns related to staffing. Multiple alert and oriented residents reported long waits for assistance, including call lights taking 30–60 minutes or up to 1.5 hours to be answered, and one resident reporting that a nurse worked six days in a row due to open shifts. Another resident reported the facility felt understaffed with CNAs, especially on day shift. A CNA reported having to work with only one other CNA in the building when others called off, and an LVN stated that staffing was an issue when staff called out and that finding replacements was difficult, with significant staff turnover in the prior six months. The administrator stated that staffing expectations were to meet state minimums, that direct care staff included CNAs, LPNs, RNs, and therapy, and that all staff clocked in and out with data sent to the vendor, but the administrator did not review PBJ data after submission, was unaware of staffing triggers or low staffing star ratings, and could not state the nursing turnover rate. The facility’s staffing policy required submission of daily direct care staffing information, including agency and contract staff, to the CMS PBJ system and directed staffing inquiries to the administrator or designee, but the incomplete PBJ submission and lack of administrative oversight led to inaccurate staffing information being reported.
Failure to Submit Quarterly PBJ Direct Care Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate payroll-based, direct care staffing information to CMS for the fourth fiscal quarter of 2025 (July 1–September 30), as required. A review of the Payroll Based Journal (PBJ) Staffing Data Report for that quarter showed a triggered concern labeled “Failed to Submit Data for the Quarter,” defined as no data submitted for the quarter. This PBJ data is intended to identify the type, number, and hours worked for clinical staff providing care to residents. During an interview, the Administrator stated that the corporate office was responsible for submitting the staffing documents to CMS and acknowledged that the information was not sent. The Administrator also confirmed awareness that submission of payroll-based direct care staffing data to CMS every quarter is required.
Inaccurate PBJ Census Data Submitted to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to CMS through the Payroll Based Journal (PBJ) system for Quarter 2 of 2025. Review of the June 2022 CMS Long-Term Care Facility PBJ Policy Manual showed facilities are required to electronically submit complete and accurate direct care staffing information, including direct care staff, category of work, resident census data, and direct care staff turnover and tenure, by the required deadlines. For Q2 (April through June 2025), the PBJ data submitted by the facility showed a reported census total of 6988. However, review of the facility’s own monthly census records showed 2266 for April, 2242 for May, and 2238 for June, for a total of 6746, revealing a discrepancy of 242 census days. During an interview, the Administrator stated that PBJ submission and census reporting were completed at the corporate level and acknowledged that issues had been identified with prior MDS submissions being timely and accurate. In an email communication, corporate staff later stated that, after reviewing all PBJ submission documents, the accurate census for Q2 was 6789, which still differed from the originally reported PBJ census total. The Administrator stated they would expect complete and accurate PBJ information to be submitted as required. This failure affected the accuracy of nursing home staffing level data collected by CMS and had the potential to impact provisions of resident care and services.
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