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F0851
F

Failure to Submit Required PBJ Staffing Data to CMS

Franklin, Massachusetts Survey Completed on 06-17-2025

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 electronically submit complete and accurate direct care staffing data to CMS for the entire reporting period of Fiscal Year Quarter 2 2025, as required by federal regulations. Review of the facility's policy indicated that it is their standard to submit timely and accurate staffing information, including agency and contract staff, in the format and schedule specified by CMS. However, the PBJ Staffing Report and CASPER Report 1705D for the relevant quarter showed that no data was submitted, resulting in a one-star staffing rating, excessively low weekend staffing, multiple days with no RN hours, and several days without 24-hour licensed nurse coverage. Interviews with facility leadership revealed that there was confusion and miscommunication regarding the submission of PBJ data. The Administrator initially believed the data had been reported but could not provide evidence of submission. The Director of Operations acknowledged an issue affecting all company buildings and stated that they were in contact with CMS. The Regional Clinical Nurse explained that the person responsible for PBJ submissions had been terminated about a month prior, and the company was under the impression that the data had been submitted. Ultimately, the Administrator confirmed that corporate was responsible for the submission, but it had not occurred for the specified quarter.

See complete original report
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