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F0851
C

Failure to Accurately Submit Staffing Data to CMS

Waukesha, Wisconsin Survey Completed on 05-21-2025

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 the complete and accurate electronic submission of direct care staffing information to CMS for Quarter 1 (October 1 - December 31) as required by federal regulations. The Payroll Based Journal (PBJ) data submitted did not accurately reflect all staffing hours, specifically omitting agency staff hours for the month of October. This omission resulted in the facility being flagged for excessively low weekend staffing and receiving a one-star staffing rating for the quarter. Review of the facility's weekend schedules and staffing ratios did not reveal discrepancies in actual staffing, indicating the issue was with the data submission rather than actual staffing levels. Interviews with the scheduler and the nursing home administrator revealed that staffing data is pulled directly from the timekeeping system and reported to CMS, but the omission of agency staff hours was not initially detected. The administrator confirmed that corporate oversight identified the missing data, and the director of nursing and unit managers were noted to assist with staffing when census was high. The deficiency had the potential to affect all 69 residents in the facility, as accurate staffing data is essential for regulatory compliance and quality monitoring.

See complete original report
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