Based on the Center of Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (January 1- March 31), facility time card records and staff interviews, the facility failed to submit accurate staff data for the PBJ Staffing Data Report. The facility reported a census of 21 residents.Findings include: The PBJ Staffing Data Report run date 7/10/2025 triggered for failure to have licensed nurse coverage 24 hours/day on the following infraction dates: 1/18, 1/24, 1/25, 1/26, 2/6, 2/16, 2/20, 2/23, 3/1, 3/2, 3/9, 3/22 and 3/23. Review of the facility report titled Detailed Hours for the infraction dates reflected the Unit Coordinator/Registered Nurse (RN) covered the nursing shifts on 1/18, 1/24,1/26, 2/6, 2/16, 2/20, 2/23, 3/1, 3/2, and 3/22. Review of facility form titled Employee Timesheet for Staff A, RN revealed Staff A covered a nursing shift on the evening/overnight of 1/24/25. On 7/16/25 at 9:50 AM, the Director of Nursing (DON) reported Staff A's nursing hours were not coded correctly and not reported to PBJ on 1/24/25. She said Staff A normally worked in the 100 hall in the hospital and the job classification was not changed when she picked up the shift.On 7/16/25 at 10:45 AM, the DON verified the Unit Coordinator/RN worked as a charge nurse on 1/18, 1/24,1/26, 2/6, 2/16, 2/20, 2/23, 3/1, 3/2, and 3/22. She reported the nursing hours were not reported to PBJ. On 7/16/25 at 11:13, the DON reported the facility does not have a PBJ policy.