Inaccurate PBJ Staffing Submission: The facility failed to submit complete and accurate direct care staffing information through PBJ. CMS data for FY 2026 Q2 showed excessive low weekend staffing, but staffing sheets showed the same number of direct care staff worked on weekends and weekdays. Administrative Staff A confirmed the facility did not have low weekend staffing and stated the DON, ADON, and MDS Nurse worked weekends as needed.
Incomplete PBJ Staffing Reporting: The facility failed to submit accurate direct care staffing data to CMS through PBJ. The PBJ report showed extremely low weekend staffing, but review of the facility’s work schedules showed the same staffing pattern on weekends as during the week, including nurses, nurse aides, and a medication aide on multiple shifts. An admin staff member stated she was unsure why the weekend staffing was reported so low and was not sure whether her hours were included in PBJ tracking.
Inaccurate PBJ staffing submission: The facility failed to submit complete and accurate PBJ staffing data based on payroll and other auditable records. The PBJ report showed no RN hours on multiple days within identified quarters and indicated a lack of 24-hour licensed nursing coverage on multiple days, even though the nursing schedule showed 24-hour licensed coverage when the Skilled Nursing Unit was open. Administrative nurses confirmed the PBJ inaccuracies and stated they had not reviewed the reports before submission.
Incomplete and inaccurate PBJ staffing submission. The facility’s PBJ reports showed excessively low weekend staffing even though actual schedules reflected the same staffing pattern on weekends as during the week, including nurses, nurse aides, and a medication aide on the shifts described. The facility assessment also documented staffing levels for each shift, and Administrative Staff A stated she was unsure why the PBJ showed low weekend staffing and believed it may have been affected by staff termination and a nurse’s death.
Incomplete PBJ Staffing Submission: The facility failed to submit complete and accurate PBJ direct care staffing data to CMS. The CASPER staffing report triggered for excessively low weekend staffing, even though the facility’s schedules showed the same staffing levels on weekends as on weekdays, including nurses, nurse aides, and medication aides. Administrative staff stated she was unsure why the weekend staffing issue occurred and said the NY office submits the PBJ from the hours the facility provides.
Inaccurate PBJ Weekend Staffing Submissions: The facility failed to submit complete and accurate PBJ direct care staffing data, with reports flagging low weekend staffing across multiple quarters. An Administrative Nurse confirmed the inaccuracies and stated she often worked weekends as the RN on duty, while another Administrative Nurse also worked weekends occasionally, but it was unclear whether that time was accurately reported. Administrative Staff reviewed the submitted data and said the weekend staffing appeared consistent with weekday staffing, though the facility continued to be flagged for low weekend staffing.
The facility failed to submit complete and accurate direct care staffing data to CMS via the PBJ system, resulting in reports that showed excessively low weekend staffing for multiple fiscal quarters. An administrative staff member acknowledged that a former business office manager had submitted the PBJ data incorrectly. This failure occurred despite a facility policy requiring uniform electronic submission of verifiable payroll data for all direct care staff, including agency and contract personnel, and specifying whether staff were employees or contracted workers.
Incomplete PBJ Staffing Submission: The facility failed to submit complete and accurate PBJ direct care staffing data based on payroll and other verifiable records. CMS PBJ reports for multiple quarters showed excessively low weekend staffing and a one-star staffing rating, even though review of staffing and nursing hours showed adequate coverage. An Administrative Nurse stated salaried nurses did not clock in when they filled in, so their hours were not counted.
Incomplete PBJ Staffing Data Submission: The facility failed to submit complete and accurate PBJ staffing data. CMS PBJ reports for multiple FY 2025 quarters showed excessively low weekend staffing, while schedule review showed adequate staff were on duty. An admin staff member stated the data were pulled from the time clock in corporate, the facility was not short on weekends, did not use agency staff, and several payroll program changes may have caused the issue. The facility policy required timely and accurate staffing data submission through CMS PBJ.
Inaccurate PBJ Staffing Submission: The facility failed to submit complete and accurate PBJ staffing data for weekend nursing coverage. Although payroll and scheduling data reflected similar weekend coverage to other days, the PBJ report showed excessively low weekend staffing because all RNs except the DON were reported under the same category, causing administrative nurses to be counted with floor nursing staff.
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