Insufficient CNA Staffing on Multiple Night Shifts
Summary
The facility failed to provide a sufficient number of certified nurse assistants (CNAs) during four night shifts out of twenty-seven reviewed, as evidenced by staffing records and interviews. On the specified dates, the number of CNAs scheduled did not meet the minimum regulatory requirement of one CNA per twenty residents, given the facility's census of over 170 residents. Staffing records showed only seven CNAs present during these shifts, which was below the facility's own staffing plan and regulatory standards. Interviews with staff confirmed that the schedule is based on census and that shortages occasionally occur, with attempts made to fill gaps using agency staff or by having the staffing coordinator work as a CNA when needed. A resident reported delays in receiving assistance with personal care and water, citing a specific incident where it took several hours to receive water after requesting it at night. Staff interviews corroborated that while the facility generally maintains adequate staffing, there have been instances of CNA shortages. The staffing coordinator confirmed reliance on agency staff and efforts to ensure coverage, but acknowledged that there were shifts with fewer than the planned number of CNAs. These findings were supported by a review of daily schedule and punch reports for the relevant period.
Penalty
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The facility failed to submit accurate PBJ staffing data to CMS. Review of the PBJ report showed triggers for excessively low weekend staffing and lack of 24-hour licensed nursing coverage, but the facility schedule and nursing census sheets showed appropriate coverage was actually in place. The BK, who was responsible for PBJ reporting, said they did not have access to the schedule and used agency bills/payroll invoices instead, and the administrator confirmed reporting was based on invoices rather than the schedule.
PBJ staffing data for Q4 2025 was submitted to CMS, but the file was rejected after validation because one employee’s hours needed correction. The Administrator and CFO stated the staff member who submitted the file was new and did not know a post-submission verification step was required, and the facility did not learn of the rejection until a CMS letter was received later; by then, resubmission was too late. The CASPER PBJ report showed the facility failed to submit the Q4 data and triggered a one-star staffing rating.
The facility failed to submit complete and accurate PBJ staffing data to CMS because the report showed no licensed nursing coverage 24 hours/day on several shifts, even though schedules, timecards, and agency invoices showed licensed nurses were scheduled and paid for all covered shifts. An LPN stated a nurse served as charge nurse every shift, and the DON said she verified licensed nurse coverage. The administrator could not explain the discrepancy and stated an agency used in 2025 had not been added to the PBJ database.
Incorrect PBJ Staffing Submission: The facility failed to accurately submit direct care staffing data to CMS for Q2 2025. The CASPER PBJ report showed staffing levels below mandated levels, and the Administrator and DON confirmed the submission was incorrect due to changes in HR staffing and the process for entering agency hours, which had been entered at month-end.
The facility failed to electronically submit complete and accurate direct care staffing information to CMS based on payroll and other auditable data for one quarter. Review of PBJ staffing data reports showed no submission for the quarter, and the NHA confirmed the facility did not submit the required direct care staffing information in the PBJ system.
The facility failed to submit required PBJ staffing data to CMS. During record review, the PBJ/CASPER report showed the quarterly submission had not been filed, and the ADM confirmed the delay was due to corporate computer issues. By the end of the survey, the facility could not provide evidence of compliance with the PBJ reporting requirement.
Incorrect PBJ Staffing Data Reported to CMS
Penalty
Summary
The facility failed to submit accurate direct care staffing information to CMS based on payroll and other verifiable and auditable data for Quarter 1 2026. Review of the PBJ Report 1705D showed that the facility triggered metrics for excessively low weekend staffing and failure to have licensed nursing coverage for 24 hours a day on 10/1/25, 10/11/25, 11/28/25, 11/29/25, 12/28/25, and 12/29/25. However, review of the facility schedule and nursing staff census sheets showed the facility did have appropriate weekend coverage and 24-hour licensed coverage, indicating incorrect data had been reported to CMS. The bookkeeper stated they were responsible for PBJ reporting, did not have access to the schedule, and used agency staffing bills as the source for reporting data, which prevented them from determining when agency staff were actually scheduled or working. The administrator confirmed the bookkeeper did not have access to the facility schedule and based reporting on payroll invoices rather than the schedule. A policy for staff reporting was requested but not provided.
PBJ Staffing Data Submission Rejected
Penalty
Summary
Electronically submitted direct care staffing information for Quarter 4, 2025 was not accepted by CMS because the facility’s PBJ file was rejected after submission. The facility sent the data file on 02/06/2026, and the CMS Final File Validation Report showed that one employee’s hours needed correction and that the file status was Rejected. The CASPER PBJ Data Report showed the facility failed to submit data for Quarter 4, 2025 and triggered a one-star staffing rating. During interview and record review on 05/28/2026, the Administrator and CFO reviewed the CMS confirmation page and the PBJ Final File Validation Report and stated the file submitted on time was rejected. The Administrator stated the staff member who submitted the file was new and did not know a post-submission verification step was required to confirm CMS accepted the data or returned it for errors. The Administrator also stated there was no notification, such as an email or error message, from CMS about questions or errors in the submission. The CFO stated the facility did not learn the file was rejected until a letter was received in the mail from CMS on 04/22/2026, and that a later attempt to resubmit the data was too late for Quarter 4 reporting.
PBJ Staffing Data Not Submitted Accurately
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to CMS through the PBJ system based on payroll and other verifiable and auditable data for Quarter 1, 2026. The PBJ Staffing Data Report triggered because it showed a failure to have licensed nursing coverage 24 hours per day on four infraction dates. However, record review of nursing staff schedules and daily staffing postings showed licensed nurses had been scheduled for 24 hours per day on each of those dates. Timecard sheets and/or agency invoices for the five employed nurses and one agency nurse covering the 12 shifts were reviewed and showed the scheduled nurses were paid for the shifts worked. During interviews, an LPN stated a nurse worked in the charge nurse capacity every shift, either an LPN or an RN. The administrator stated the facility scheduled one licensed nurse each shift and verified all shifts were covered, but could not explain the discrepancy. He later stated the person who uploaded the data had not been informed the facility had started using a particular agency in 2025 and had not added those agency nurses to the database. The DON stated she did the nursing schedules and verified a licensed nurse was scheduled as the charge nurse for each shift.
Incorrect PBJ Staffing Submission
Penalty
Summary
The facility failed to ensure that direct care staffing information, including agency and contract staff hours, was electronically submitted correctly to CMS for Quarter 2 of 2025 through the PBJ staffing submission process. Review of the CASPER Payroll-Based Journal Staffing Data Report showed the facility reported staffing data for April 1, 2025 through June 30, 2025 at a level lower than the required mandated staffing levels. During interview, the Administrator and DON confirmed the PBJ data submitted for Quarter 2 was incorrect and stated the inaccuracies were related to a change in the facility's HR staffing and the process used to enter agency staff hours. The Administrator stated agency staff hours had been entered at the end of the month, making it difficult to identify discrepancies, and that the facility had been entering agency hours within one to two business days starting in July 2025.
Failure to Submit PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS based on payroll and other verifiable and auditable data for one of the last four quarters, identified as Quarter 1 2026. Review of the ACA Section 6106 requirements and the PBJ staffing data reports showed that the facility did not submit staffing data for Quarter 1, listed as October 1 through December 31, 2026. During an interview on 5/21/26 at 1:10 p.m., the Nursing Home Administrator confirmed that the facility failed to submit direct care staffing information in the Payroll-Based Journal system as required.
Failure to Submit Required PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate Payroll Based Journal (PBJ) direct care staffing information to CMS based on payroll and other verifiable and auditable data. During a concurrent interview and record review, the PBJ/CASPER report for fiscal year Quarter 1, 2026 (October 1 through December 31) was reviewed and showed that the report had not been submitted for that quarter. The Administrator confirmed the report was not submitted because the corporation had computer issues and the facility could not submit the PBJ report on time. By the end of the survey, the facility was unable to provide evidence that it had complied with the requirement to submit PBJ data and reports to CMS.
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