F 0851
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and
other verifiable and auditable data.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to follow guidelines for mandatory submission of staffing
information based on payroll data in a uniform format. Long-term care facilities must electronically submit to
CMS complete and accurate direct care staffing information, including information for agency and contract
staff, based on payroll and other verifiable and auditable data in a uniform format according to
specifications established by CMS, in that:
The facility failed to submit staffing information to CMS for the 3rd quarter (April, May, June) of the fiscal
year 2023.
This failure could place residents at risk for personal needs not being identified and met, decreased quality
of care, decline in health status, and decreased feelings of well-being within their living environment.
Findings included:
Review of the facility's staff roster, 12/03/2023 indicated the following:
1 Administrator
1 Nurse manager
1 MDS
5 RNs
3 LVNs
6 MAs
5 CNAs
Record review of the facility state form 3761 Civil Rights (Civil Rights Survey Report Titles VI and VII of the
Civil Rights Act of 1964)) dated12/03/2023 provided by Administrator indicated a total of 84 residents in the
facility.
Record review of the PBJ Staffing Data Report, FY Quarter 3 2023 (April 1 - June 30) (), dated
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
675424
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675424
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/05/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Advanced Rehabilitation and Healthcare of Athens
121 Commons Drive
Athens, TX 75751
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0851
11/30/2023, revealed the facility had failed to submit data for the quarter.
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 12/03/2023 at 3:45 PM, the Administrator said the PBJ reports she thinks are
submitted by the HR Director who is not here today. The ADON who does the staffing had no idea who
submits the PBJ report. were submitted by the accounting department at the corporate office and all hours
were not accurately captured and reported due to an error with the payroll system. It failed to include
agency staffing or salaried employees in the reported hours. She said they were not familiar with the
requirement for reporting staffing to CMS, because she was not responsible for reporting for the facility. She
said the facility did not have a Payroll Based Journal for submission to CMS policy.
Residents Affected - Many
During a Record review of the PBJ labeled ([NAME] 04/01/2023 - 06/30/2023 exported on 08/03/2023
10:22 AM. The Administrator said this information was only exported from the facility and had not been
submitted information to CMS.
During an interview on 12/05/2023 at 2:50 PM, the Regional RN Consultant and Facility Administrator both
stated that the corporate office had failed to submit the PBJ by the deadline for the 3rd quarter. They both
said that they do not have anything to do with PBJ reporting.
Record review of the CMS, Electronic Staffing Data Submission Payroll-Based Journal, Long-Term Care
Facility Policy Manual, Version 2.6, June 2022, section 1.2 Submission Timeliness and Accuracy, revealed
Direct care staffing and census data will be collected quarterly, and is required to be timely and accurate.
Further review revealed Report Quarter 3 date range as April 1- June 30,2023. Policy manual revealed,
Deadline: Submissions must be received by the end of the 45th calendar day (11:59 PM Eastern Time)
after the last day in each fiscal quarter in order to be considered timely.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675424
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675424
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/05/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Advanced Rehabilitation and Healthcare of Athens
121 Commons Drive
Athens, TX 75751
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0868
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Level of Harm - Minimal harm
or potential for actual harm
Based on an interview and record review, the facility failed to ensure that the facility's medical director or
his/her designee attended the Quality Assessment and Assurance/Quality Assurance and Performance
Improvement Committee meetings, for 1 of 1 facility, reviewed for QAA/QAPI.
Residents Affected - Some
The facility failed to ensure the medical director attended their QAA and QAPI meetings for the months of
December 2022, February 2023, July, August, September and October 2023.
This failure could place residents at risk for quality deficiencies being unidentified and no appropriate plans
of actions developed or implemented.
Findings included:
Review of the facility's QAA/QAPI meeting signature logs for the months of December 2022, February
2023, July, August, September, and October 2023 revealed, meetings were conducted each month during
that period. Neither the Medical Director nor his/her designee signed the sign-in sheets, nor was it indicated
on the sign-in sheet that the Medical Director or his designee attended the QAA/QAPI meetings for
December 2022, February 2023 and July, August, September, and October 2023, via zoom or by phone.
The signature sign-in log also indicated, the Medical Director only attended 5 of 12 monthly QAA/QAPI
meetings.
During an interview on 12/05/2023 at 3:07 PM, the Administrator said the Medical Director receives
notification of the QAA/QAPI meeting from the DON. She said some of the meetings were held before she
became administrator.
During an interview on 12/05/2023 at 4;15 PM, the DON said she notifies the Medical Director of the
QAA/QAPI meetings by phone or text. She said sometimes the Medical Director was in the facility and she
would notify him of the meeting verbally. The DON did not say why the Medical Director had missed several
meetings.
Review of the facility's policy Quality Assessment and Assurance Committee, dated 10/24/2022, revealed,
Policy Explanation Compliance Guideline: 1. the QAA committee will be composed of, at a minimum: a. The
Director of Nursing, b. The Medical Director or his/her designee .5 the QAA committee .a. Meet at least
quarterly as needed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675424
If continuation sheet
Page 3 of 3
