Finding Description
Based on record review and staff interviews, the facility failed to submit accurate payroll data on the Payroll Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS) related to Registered Nurse (RN) hours and licensed nursing coverage 24-hours per day. This was reviewed for 1 of 3 Federal Fiscal quarters for sufficient nurse staffing (Quarter 1 which ranged from October 1, 2025 through December 31, 2025). Findings included:Review of the PBJ for Federal Fiscal Year Quarter 1 2025 (October 1st through December 31st) revealed system triggers for no Registered Nurse (RN) hours from October 16th 2025 through December 31st 2025, as well as no licensed nursing coverage on October 5, 2025, October 11, 2025 and October 16, 2025 through December 31, 2025. Detailed review with the Assistant Director of Nursing (ADON) of the Posted Daily Nursing Staffing Forms, Daily Staffing Sheets, and the nursing staff time detail reports for October 5th through October 31st, for each day of November 2025 and for each day of December 2025 revealed there was an RN on site for at least 8 hours every 24 hours and there was licensed nursing coverage at the facility 24 hours a day for all aforementioned dates.On 3/17/26 at 11:00 AM, a joint interview with the Administrator and the Assistant Director of Nursing (ADON) was conducted. The Administrator said she became aware of a potential PBJ issue when she learned of a 1 star staffing rating on 2/17/26. The Administrator said the 1 star rating on 2/17/26 was the first they knew they had a problem with the PBJ report submissions for Quarter 1. The ADON said she did the scheduling and staffing and she always ensured there was RN and licensed nurse coverage every day but she did not do the final PBJ submissions to CMS. The Administrator said the final submission of the PBJ staffing data was done by the facility's Controller. The Administrator said they ensured they have RN coverage and nurse coverage every day. An interview with the facility's Controller was conducted on 3/17/26 12:33 PM. The Controller confirmed he had worked at the facility for 8 years and he had been doing the PBJ submissions for that duration. The Controller said he received all nurse staffing information from the online staffing computer system used by the facility, after staffing was entered and completed by the ADON. The Controller said he put all staffing information onto a computer spreadsheet and uploaded the spreadsheet into the staffing computer system, which system then converted the data from the spreadsheet file into a different type of file acceptable to CMS. The Controller added CMS did not accept spreadsheet files for PBJ submissions so this file conversion step had to be done. The Controller said he verified all actual nursing hours from the facility's payroll system to ensure he had all necessary nursing hour coverage for submission. The Controller confirmed, I don't prorate hours down for only the 6 skilled beds specifically, I credit the RN for the actual hours required only. The Controller said he had to log into the CMS site where he submits payroll data in order to see CMS validation messages. The Controller said any validation message not only confirms the submission but also flags a potential issue. The Controller said he logs into the CMS system once every quarter when he submits the payroll data. The Controller said he did not receive CMS alerts directly to his email. The Controller said he had not reached out to CMS specifically about this issue because he did not know about it, and said the Administrator also checked for issues and kept up with it. The Controller said he was at a loss to understand what was happening because he had all the data supporting required nursing coverage and he submitted it as he had it and the first he knew there was a problem with quarter 1 was at this interview. In a follow up interview with the Administrator on 3/17/26 at 2:20 PM, the Administrator said she did not reach out to CMS after 2/17/26 because she only knew they had dropped to a 1 star staffing rating but did not know why, as they had received no specific alert messages indicating a problem. The Administrator said the facility had therefore obtained a consultant to get assistance on ascertaining the reason for the drop and how to correct the issue as soon as possible to ensure their PBJ staffing data was submitted correctly but she did not know that RN and licensed nurse coverage was the issue until this survey.