Based on interview and record review, the facility did not ensure accurate reporting of the mandatory submission of staffing information based on payroll data to the Centers for Medicare & Medicaid Services (CMS). This has the potential to affect all 11 residents residing within the facility. The facility failed to enter accurate data in their Payroll Based Journal (PBJ) reporting and triggered for five fiscal year quarters for failure to have licensed nursing coverage 24 hours a day. Evidenced by: (It is important to understand the foundation of this facility to grasp where these errors are occurring. This facility campus houses residents in 7 different licensed entities. There is one Brain Injury Center, one Skilled Nursing Facility, one unit for Individuals with Intellectual Disabilities, and four Behavioral Health units. Although these entities are separate licenses, they share one big campus and share some of the staff members like the Director of Nursing, the Facility Administrator, and RN Supervisors (Registered Nurse). Facility policy, entitled How to do the PBJ Report for CMS, undated, includes: You will need to get the RN (Registered Nurse) staffing assignments by zone . these will help you pro-rating the licensed staff and determine where they worked . The following administrative staff get pro-rated:1) Pro-rated based on # of beds: 51% other facility licenses, 13% to this facility's license: Director of Nursing Services, Executive Director, Assistant Director of Nursing, Director of Dietary Services, Registered Nurse Practitioner, In-Service Coordinator. 2) Pro-rated based on workload: 75% other facility licenses, 3% to this facility's license: Director of Life Enrichment Services. 3) Pro-rated based on workload: 50% other facility licenses, 50% to this facility license: Director of Social Services Coordinator. 4) Pro-rated based on workload: . Admissions Clinical Coordinator. 5) Pro-rated based on workload: 75% other facility licenses, 18.4% this facility license: Minimum Data Set Coordinator . The following are how the Team Leaders and RN Supervisors get pro-rated: Team Lead AM: 100% this facility license, Team Lead PM: 100% this facility license, Team Lead Night Shift (NOC): 60% this facility license . RN Supervisor Weekend: AM-20% this facility license, PM-20% this facility license, NOC- 20% this facility license . RN Supervisor Weeks: AM- 100% this facility's license, PM-20% this facility license, NOC- 20% this facility license . Determining/Pro-rating Hours: RNs who work the PM shift are pro-rated so that 20% of their time goes to this facility license, 80% goes to other facility licenses, This applies to the AM shift on the weekends . Team Leaders who work the NOC shift are pro-rated so that 60% of their time goes to this license and 40% of their time goes to another license. Certified Nursing Assistants who work on a different household are 100% allocated to that household. Example 1: CMS's PBJ Staffing Data Report, for fiscal year quarter 3 2023 (April 1-June 30), includes: Failed to have licensed nursing coverage 24 hours a day . Triggered four or more days within the quarter with less than 24 hours per day licensed nursing coverage . Possible reason for suppressed metrics: invalid data . Infraction dates: 4/2, 4/7, 4/8, 4/9, 4/16, 4/23, 4/29, 4/30, 5/13, 5/14, 5/20, 5/21, 5/26, 5/28, 5/29, 5/30, 6/2, 6/3, 6/4, 6/10, 6/11, 6/18, 6/24, 6/25, 6/30 CMS [NAME] Report Staffing Summary Report, from 4/1/23 thru 6/30/23, includes, in part: 4/2 licensed nursing hours reported: 23.25. 4/7 licensed nursing hours reported: 22.95. 4/8 licensed nursing hours reported: 13.55. 4/9 licensed nursing hours reported: 15.70. 4/16 licensed nursing hours reported: 16.3. Example 2: CMS's PBJ Staffing Data Report, for fiscal year quarter 4 2023 (July 1-September 30), includes: Failed to have licensed nursing coverage 24 hours a day . Triggered four or more days within the quarter with less than 24 hours per day licensed nursing coverage . Possible reason for suppressed metrics: invalid data . Infraction dates: 7/1, 7/2, 7/3, 7/5, 7/6, 7/8, 7/9, 7/15, 7/16, 7/22, 7/23, 7/24, 7/29, 7/30, 8/1, 8/4, 8/7, 8/12, 8/13, 8/17, 8/18, 8/19, 8/22, 8/26, 8/27, 8/29, 9/9, 9/10, 9/23, 9/24 CMS [NAME] Report Staffing Summary Report, from 7/1/23 thru 9/30/23, includes, in part: 7/1 licensed nursing hours reported: 15.72. 7/2 licensed nursing hours reported: 17.90. 7/3 licensed nursing hours reported: 18.30. 7/5 licensed nursing hours reported: 22.68. 7/6 licensed nursing hours reported:20.81. Example 3: CMS's PBJ Staffing Data Report, for fiscal year quarter 1 2024 (October 1-December 31), includes: Failed to have licensed nursing coverage 24 hours a day . Triggered four or more days within the quarter with less than 24 hours per day licensed nursing coverage . Possible reason for suppressed metrics: invalid data . Infraction dates:10/1, 10/4, 10/6, 10/7, 10/8, 10/21, 10/22, 10/27, 11/4, 11/12, 12/25, 12/29 CMS [NAME] Report Staffing Summary Report, from 10/1/23 thru 12/31/23, includes, in part: 10/1 licensed nursing hours reported: 16.65. 12/25 licensed nursing hours reported: 17.47. 12/29 licensed nursing hours reported: 15.10. On 5/8/24 at 10:19 AM, BOM C (Business Office Manager) indicated she is responsible for completing the PBJ reporting, and she uses an equation to divide the licensed nursing hours amongst the different licensed entities in the home. BOM C indicated there is a licensed staff working 24 hours a day in this licensed entity. BOM C indicated on paper their hours are split between other licensed entities within the home. Surveyor asked if this is a true representation of the schedules if the staff are working for 8 hours, but only count as a percentage of that on the PBJ. BOM C indicated this is how she has been taught and has always done it this way. On 5/8/24 at 1:19 PM, DON B (Director of Nursing) indicated at no time is this unit left without a licensed nursing staff. There is a licensed nursing staff scheduled on all three shifts for only this unit and sometimes two licensed staff are scheduled. DON B indicated time for RN Supervisors is split between licenses. Surveyor asked if the reported data reflects this. DON B indicated it does not. On 5/8/24 at 2:08 PM, Payroll Coordinator D indicated there is never a time where there is no licensed nurse on the unit. Payroll Coordinator D indicated the data reported does not reflect that there is 24-hour licensed nurse coverage. On 5/8/24 at 3:26 PM, Rehabilitation Specialist E indicated there is never a time that the unit does not have a licensed nurse on it. On 5/8/24 at 3:27 PM, Social Worker F indicated there is always a licensed nurse on the unit. At no times is the unit without nurse coverage. It should be noted, a review of the licensed nursing schedule reflects a licensed nurse on the unit every shift.