Inconsistent Weekend Staffing in Facility
Summary
The facility did not ensure consistent staffing on weekends to meet the needs of the 30 residents residing in the facility. During the review of the payroll-based journal (PBJ) staffing data for the first quarter of the federal fiscal year 2023, the facility was flagged for excessively low weekend staffing. The facility's assessment indicated that the average daily census was between 28 to 32 residents, requiring 5 licensed nurses and 8 certified nursing assistants (CNAs) to provide direct care. The staffing requirements included having one registered nurse (RN) or licensed practical nurse (LPN) per shift, with specific ratios for day, PM, and night shifts. However, the facility's PBJ data revealed a discrepancy in staffing levels, particularly on weekends. The Director of Nursing (DON) stated that the facility's staffing needs are determined by the census and acuity of residents, using a scheduling program called Smart Linx. Despite the program's algorithm creating an ideal schedule, the facility was still triggered for low weekend staffing. The Regional Vice President (VP) acknowledged that the facility was automatically down 16 hours on weekends due to the absence of certain staff roles, such as the Minimum Data Set (MDS) nurse and Social Services. Additionally, a systemic issue was identified where agency staff hours were not being accurately pulled into the PBJ reporting, affecting the reported weekend staffing hours. This issue was attributed to a checkbox in Smart Linx not being checked, which led to agency hours not being integrated into the system, impacting the facility's staffing data.
Penalty
Resources
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The facility failed to submit accurate and complete PBJ staffing data to CMS for a quarter in which the PBJ report showed excessively low weekend staffing. The staffing coordinator stated weekend coverage was scheduled with at least one RN per shift and that the charge nurse found replacements for call-ins, while the administrator stated the low staffing was identified on the first weekend in November and that inaccurate reporting occurred. A requested PBJ policy was not provided.
The facility failed to submit complete and accurate PBJ staffing data to CMS when contract nursing hours were omitted from the PBJ report. The LNHA stated he compiled and submitted PBJ data using corporate employee files and separately received vendor data for contract staff, but later confirmed that contract nursing hours were not included for several dates. The PBJ staffing report also identified excessively low weekend staffing, while the DON stated staffing was based on resident acuity and the facility assessment and that the schedule supported a census of 55 residents.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
The facility failed to submit accurate PBJ staffing data for one quarter reviewed. The Administrator and PBJ Coordinator confirmed that DON, RN, and LPN administrative hours were included in PBJ even when those staff did not provide direct resident care, and the CASPER report triggered for excessively 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.
The facility failed to submit accurate PBJ staffing data for the reporting period. Review showed excessively low weekend staffing was reported even though daily staffing assignment sheets reflected sufficient staffing across morning, evening, and night shifts with several RNs and CNAs working. An RN said the low staffing was tied to a prior audit issue while using an outside PBJ module that double-counted employee hours, and the DON stated the facility had no policy for correct PBJ submission and just followed the regulations.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to submit accurate and/or complete direct care staffing information to CMS based on payroll and other verifiable and auditable data during Quarter 1 of fiscal year 2026. The PBJ staffing data report showed excessively low weekend staffing for the quarter covering October 1 through December 31, 2025. During an interview, the staffing coordinator stated she was responsible for nurse staff schedules, that at least one RN was scheduled per shift, and that weekends were covered, with the charge nurse responsible for finding replacements when staff called in. During a later interview, the administrator stated the low staffing was found on the first weekend in November 2025 and that the PBJ report was submitted after corporate pulled and reviewed the information; the administrator also stated there was inaccurate reporting. A requested facility policy for PBJ was not provided.
Incomplete PBJ Staffing Submission
Penalty
Summary
The facility failed to ensure accurate and complete submission of direct care staffing information through the PBJ system to CMS for one fiscal year quarter. The facility policy required electronic submission of complete and accurate staffing information, including agency and contract staff, based on payroll and other verifiable and auditable data. During interview, the LNHA stated he was responsible for compiling and submitting PBJ data, using employee staffing data received from the corporate office and contract nursing staffing data received separately from vendors and manually entered into the PBJ system. The LNHA later confirmed that the data transmitted from the corporate software system was not accurately submitted to the CMS PBJ system and that contract nursing staffing hours for 10/25/2025, 11/22/2025, 12/06/2025, 12/19/2025, 12/27/2025, and 12/28/2025 were not included in the PBJ submission. Record review confirmed those contract nursing staffing hours were omitted. The PBJ Staffing Data Report for FY Quarter 1 2026 identified concerns related to excessively low weekend staffing. The DON stated she and the Staffing Coordinator were responsible for staffing, that staffing was based on resident acuity and the facility assessment, and that the current schedule supported a census of 55 residents with call outs managed without staffing issues. Record review of staffing schedules and daily staffing sheets revealed no staffing shortages or concerns.
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Inaccurate PBJ Staffing Reporting
Penalty
Summary
The facility failed to submit accurate staffing data into the Payroll-Based Journal (PBJ) system for one quarter reviewed, specifically the 4th Quarter 2025 (July 1-September 30). Review of the facility policy on reporting direct-care staffing information showed that staffing and census information are to be reported electronically to CMS through the PBJ system in compliance with Section 6106 of the Affordable Care Act. Review of the PBJ Staffing Data Report CASPER Report 1705D for FY Quarter 4 2025 showed the facility triggered for excessively low weekend staffing. During interview, the Administrator and PBJ Coordinator confirmed the facility included DON hours, RN administrative hours, and LPN administrative hours in PBJ reporting even when those staff did not provide direct resident care. The Administrator stated that entering those hours incorrectly increased the number of staff shown during the week and caused staffing numbers to fall on the weekends.
Inaccurate PBJ Submission Resulting in Underreported Weekend Staffing
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS through the Payroll Based Journal (PBJ) system as required, resulting in reported staffing levels that did not reflect actual staffing. CMS PBJ reports for Fiscal Year 2026 Quarter 1 and Fiscal Year 2025 Quarter 3 showed excessively low weekend staffing, indicating that the data submitted did not accurately capture direct care staff hours. During an interview, an administrative staff member acknowledged awareness of a problem and reported that the previous Business Office Manager had submitted the PBJ information incorrectly. The facility’s own PBJ F851 policy required submission of payroll data in a uniform CMS-specified format for all direct care staff, including community, agency, and contract staff, and required that the data distinguish between employees and contracted or agency staff, but this policy was not followed, leading to incomplete and inaccurate staffing information being reported.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to submit accurate direct care staffing information in the CMS Payroll Based Journal (PBJ) Staffing Data Report for the October 1 through December 31 reporting period. Review of the PBJ Staffing Data Report showed the facility triggered for excessively low weekend staffing, and the submitted weekend staffing data was found to be excessively low. However, review of facility daily staffing assignment sheets for October through December showed sufficient staffing across the morning, evening, and night shifts, with several nurses and CNAs working those shifts. During interview, an RN stated the low weekend staffing was related to a failed audit for the prior quarter while the facility was using an outside PBJ module, and that the outside company had double-counted hours for several employees, causing over-reporting in that quarter. The DON stated the facility had no policy for correctly submitting PBJ and simply followed the regulations.
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