F0851

E

Inaccurate PBJ Staffing Data Submission and Reported Delays in Resident Assistance

Prescott, Arizona Survey Completed on 03-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that direct care staffing information submitted to CMS through the Payroll-Based Journal (PBJ) system was complete and accurate, based on verifiable and auditable data. PBJ reports showed the facility consistently triggered for excessively low weekend staffing for three quarters and received a one-star staffing rating for two fiscal quarters. The facility assessment documented a licensed capacity of 58 residents with a current census of 50 and indicated daily nursing staffing of three nurses on day shift and two on night shift, with an RN present at least 8 consecutive hours per day and three CNAs on night shift and four on day shift. However, when surveyors requested detailed staffing submission data, the administrator stated that timeclock data went to a vendor (Xchieve) which then submitted to CMS, and that the information was located out of state and not immediately available. Review of the PBJ submitter final file validation report obtained from the facility showed that the Total Employee Link Records portion failed to be submitted.

Resident and staff interviews and facility documentation further demonstrated discrepancies and concerns related to staffing. Multiple alert and oriented residents reported long waits for assistance, including call lights taking 30–60 minutes or up to 1.5 hours to be answered, and one resident reporting that a nurse worked six days in a row due to open shifts. Another resident reported the facility felt understaffed with CNAs, especially on day shift. A CNA reported having to work with only one other CNA in the building when others called off, and an LVN stated that staffing was an issue when staff called out and that finding replacements was difficult, with significant staff turnover in the prior six months. The administrator stated that staffing expectations were to meet state minimums, that direct care staff included CNAs, LPNs, RNs, and therapy, and that all staff clocked in and out with data sent to the vendor, but the administrator did not review PBJ data after submission, was unaware of staffing triggers or low staffing star ratings, and could not state the nursing turnover rate. The facility’s staffing policy required submission of daily direct care staffing information, including agency and contract staff, to the CMS PBJ system and directed staffing inquiries to the administrator or designee, but the incomplete PBJ submission and lack of administrative oversight led to inaccurate staffing information being reported.