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F0851
F

Inaccurate RN Staffing Data Submitted Due to Agency Nurses Not Clocking In

Winston-salem, North Carolina Survey Completed on 08-22-2025

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 via the Payroll Based Journal (PBJ) system for one of three reviewed quarters, specifically regarding Registered Nurse (RN) hours. The PBJ report for the specified quarter showed no RN hours recorded on four dates, while daily staff schedules indicated that an RN was onsite for at least eight hours on those days. Nursing staff time detail reports, however, did not reflect the presence of an RN, aligning with the PBJ data. Interviews with the Scheduling Coordinator revealed that agency RNs sometimes did not clock in upon arrival, resulting in their hours not being captured in the facility's timecard system or the PBJ submission. The Administrator confirmed unawareness of this issue and acknowledged that all staff, including agency nurses, are required to document their time in the system.

See complete original report
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