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F0851
F

Failure to Submit Required PBJ Staffing Data to CMS

Big Lake, Texas Survey Completed on 05-15-2025

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 comply with federal requirements for electronically submitting complete and accurate direct care staffing information to CMS using Payroll Based Journal (PBJ) data. Specifically, the facility did not submit the required PBJ staffing information for Fiscal Year Quarter 1 2025 (October 1 - December 31). Review of the CASPER Report 1705D for this period showed no data was submitted for the quarter, triggering a deficiency. The facility's employee list indicated the presence of various staff, including RNs, LVNs, CNAs, and other personnel, and the census showed a total of 27 residents at the time of the deficiency. During an interview, the Chief Financial Officer (CFO) stated that this was her first time submitting the PBJ data independently and believed she had completed the process, but later realized the submission did not go through. The CFO was unaware that an email confirmation was required and did not follow up, resulting in the missed deadline and inability to submit the data retroactively. The deficiency was identified through record review and staff interview, with no PBJ data available for the specified quarter.

See complete original report
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