Failure to Submit Accurate Direct Care Staffing Data
Penalty
Summary
The facility failed to submit accurate direct care staffing information to CMS as required. Review of the Payroll Based Journal (PBJ) Staffing Data Report for the first quarter of fiscal year 2025 revealed multiple triggers, including a One Star Staffing Rating, excessively low weekend staffing, no Registered Nurse (RN) hours, and lack of licensed nursing coverage for 24 hours per day. The infractions for no RN hours and lack of licensed nursing coverage occurred throughout December 2024. During an interview, the administrator responsible for PBJ uploads confirmed that the PBJ Final Validation Report for December 2024 was not available and acknowledged that the codes for direct care staffing were not accurately transferred to the PBJ report for that month.