Failure to Submit Required Direct Care Staffing Data
Penalty
No penalty information released
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 electronically submit complete and accurate direct care staffing information to CMS as required. Review of the Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year Quarter 1 2025 revealed that the facility did not submit RN hours for any day during the 92-day quarter and failed to document licensed nursing coverage for 24 hours each day throughout the same period. These omissions resulted in triggers for a One Star Staffing Rating, excessively low weekend staffing, no RN hours, and lack of 24-hour licensed nursing coverage. During an interview, the administrator responsible for PBJ submissions confirmed that the required staffing information was not accurately submitted for the quarter.