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F0851
C

Inaccurate Submission of Staffing Data to CMS

Laona, Wisconsin Survey Completed on 06-18-2025

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 that complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data, was submitted to the Centers for Medicare & Medicaid Services (CMS) as required. During a review of the Payroll Based Journal (PBJ) Staffing Data Report for the second fiscal quarter, the surveyor noted that the facility triggered for excessively low weekend staffing. However, upon review of timecard punches and staffing totals for the same period, it was found that there were no low weekend hours and the facility consistently maintained nursing hours above the required minimum. The facility assessment also confirmed that staffing was appropriate for the resident population. Interviews with the Business Office Manager (BOM) and Director of Operations (DOO) revealed that the facility reviews staffing hours daily to ensure accurate reporting, but the employee responsible for submitting the PBJ data was on medical leave and unavailable for clarification. Both the BOM and DOO were unable to explain why the PBJ report indicated low weekend staffing, suspecting a possible error in the reporting or timecard system, particularly regarding agency staffing hours. This discrepancy resulted in the submission of inaccurate staffing data to CMS, potentially affecting all 34 residents in the facility.

See complete original report
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