Inaccurate PBJ Staffing Data Submission Leads to Deficiency
Penalty
Summary
The facility failed to ensure that the mandatory staffing data submitted to CMS for the first quarter of 2025 was accurate. During the review of the Payroll-Based Journal (PBJ) staffing data, the facility was flagged for excessively low weekend staffing, which had the potential to affect all 67 residents. The facility is licensed for 100 residents, with specific staffing requirements per shift and unit. Surveyors reviewed daily staff schedules and postings for the relevant period and confirmed that both Licensed Nurses and Certified Nursing Assistants (CNAs) were present on each shift and unit, with call-ins and replacements documented. Despite the presence of staff as per the schedules, the facility's PBJ data indicated low weekend staffing due to issues in how staff hours were reported and coded. The Scheduler stated that staffing was determined by census and acuity, and was unaware of the reason for the low staffing trigger, noting that unit managers were included in reportable staffing during the week but not on weekends. The Nursing Home Administrator later identified that training/orientation hours were not captured in the reporting, and that unit managers and the Infection Control Nurse, who were coded as direct care during the week, did not work weekends, resulting in a significant drop in reported direct care hours on weekends.