Failure to Timely Submit Required Staffing Data to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to CMS for fiscal year quarter 2 of 2025, as required. The Administrator, who is responsible for submitting staffing data based on payroll records, acknowledged that the submission for the quarter was made one day after the deadline due to a change in staff. As a result, the CASPER PBJ Staffing Data Report indicated that no data was submitted for the quarter, which was defined as a trigger for non-compliance. At the time of the survey, there were 32 residents living in the facility, as confirmed by both facility documentation and the Administrator during interviews. This deficiency was identified through record review and interviews, with the Administrator confirming both the number of residents and the late submission of required staffing data.