Failure to Submit Required Staffing Data to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for the first quarter of 2025, as required. Review of the Payroll Based Journal (PBJ) Staffing Data Report showed that staffing data for the period from October 1st to December 31st, 2025, was not submitted, resulting in the facility receiving a one-star staff rating. During interviews, the Chief of Operation (CEO) confirmed there was no documented evidence that the required staffing data had been reported to CMS. The CEO explained that the facility underwent a change of ownership in December 2024, and it was the previous owner's responsibility to report the staffing data. The CEO also stated that the previous owner had sent the data to a contracted company, which was responsible for submitting it to CMS, but there was no documentation to confirm that this submission occurred. This deficiency had the potential to affect all 72 residents in the facility.