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F0851
D

Failure to Accurately Report Staffing Hours in PBJ Submission

Bellingham, Washington Survey Completed on 07-11-2025

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 accurate submission of Payroll Based Journal (PBJ) data to CMS for Fiscal Year Quarter 4, 2024. The PBJ report submitted included only hours worked by facility-employed staff and omitted hours worked by agency or contracted staff, resulting in 28,907.80 hours unaccounted for in the report. This omission led to the facility not meeting the minimum required 3.4 Hours Per Resident Day (HPRD) and being short by 920 hours. The process for PBJ reporting involved the corporate office preparing the report, sending it to the administrator for review and approval, and then submitting it, but the failure to include agency staff hours was confirmed by the Chief Operating Officer. The inaccurate data submitted to CMS affected the reported staffing levels for the entire facility.

See complete original report
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