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F0851
F

Failure to Accurately Submit Staffing Data to CMS

Two Harbors, Minnesota Survey Completed on 06-05-2025

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 ensure that complete and accurate direct care staffing information was electronically submitted to CMS for one of four quarters reviewed. Specifically, the Payroll Based Journal (PBJ) report for quarter 3 of 2024 indicated that the facility did not have licensed nursing coverage for 24 hours on several dates, and also triggered a low weekend staffing metric. However, a review of timecards for the listed dates showed that licensed nursing staff were present and provided 24-hour coverage on each date. During an interview, the administrator, associate administrator, and corporate nurse were unaware of any issues with the staffing data submission and could not explain the discrepancy, though the associate administrator speculated it might be related to agency staff usage. No policy on PBJ submission was provided.

See complete original report
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