Incomplete and Inaccurate PBJ Staffing Submission: The facility failed to submit complete and accurate PBJ staffing data based on payroll and other auditable records. CMS PBJ reports showed excessively low weekend nurse staffing across multiple FY quarters, while review of weekend nursing schedules and working hours showed adequate staffing. An admin staff member stated the administrator and corporate staff were responsible for PBJ submission, and the facility policy required PBJ data to be submitted in a uniform format to CMS.
Incomplete PBJ staffing reporting led to a trigger for excessively low weekend staffing. CMS PBJ data for FY 2026 Q1 and Q2 showed low weekend staffing, but review of nursing schedules showed adequate staffing on duty. An Administrative Nurse stated the Administrator submitted the PBJ nursing information and that weekends were always staffed well, including with agency staff when needed. The facility’s PBJ policy required reporting payroll data for employees, agency, and contract staff.
Inaccurate PBJ staffing submission: The facility failed to electronically submit complete and accurate direct care staffing data to CMS through PBJ. Review of the PBJ Staffing Data Report showed excessively low weekend staffing for multiple quarters, but the nursing schedule and payroll data did not reflect lower weekend staffing than weekdays. An admin staff member stated corporate changed the PBJ report to code admin nurses' weekend hours as direct care, even though staffing levels were the same on weekends and weekdays.
The facility failed to submit complete and accurate PBJ staffing data to CMS based on payroll and other verifiable records. CMS PBJ data for two quarters showed excessively low weekend staffing, and an admin staff member stated staffing information was sent to corporate for CMS submission but could not confirm whether the data submitted was incorrect. The facility could not provide a PBJ policy.
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 and inaccurate PBJ staffing submission. CMS PBJ reports for multiple quarters showed excessively low weekend staffing even though the facility schedule reflected adequate weekend coverage. An admin staff member said timesheets and payroll forms were compared and sent to corporate for submission, but another admin staff member stated that administrative staff had been mistakenly reported as hands-on staff during the week and then not counted on weekends.
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.
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