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F0851
F

Failure to Accurately Submit Weekend Staffing Data to CMS

Janesville, Minnesota Survey Completed on 08-06-2025

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 submit accurate direct care staffing information to CMS for Quarter 2, 2025, as required by federal regulations. The CMS payroll-based journal (PBJ) staffing data report indicated excessively low weekend staffing, which was not consistent with the facility's actual staffing levels. During interviews, the DON stated uncertainty about the low staffing trigger and confirmed that staff, including agency staff, were always present on weekends. The administrator, responsible for PBJ data submission, acknowledged a possible delay in receiving agency staffing hours, which may have led to the inaccurate data submission. Review of the facility's master nursing staff schedule and time card reports confirmed that there was no actual low weekend staffing during the reviewed period. The facility did not provide a policy on PBJ submission.

See complete original report
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