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F0851
F

Failure to Submit Quarterly PBJ Direct Care Staffing Data to CMS

Lapeer, Michigan Survey Completed on 03-04-2026

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 electronically submit complete and accurate payroll-based, direct care staffing information to CMS for the fourth fiscal quarter of 2025 (July 1–September 30), as required. A review of the Payroll Based Journal (PBJ) Staffing Data Report for that quarter showed a triggered concern labeled “Failed to Submit Data for the Quarter,” defined as no data submitted for the quarter. This PBJ data is intended to identify the type, number, and hours worked for clinical staff providing care to residents. During an interview, the Administrator stated that the corporate office was responsible for submitting the staffing documents to CMS and acknowledged that the information was not sent. The Administrator also confirmed awareness that submission of payroll-based direct care staffing data to CMS every quarter is required.

See complete original report
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