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F0851
F

Failure to Accurately Report Staffing Data and Maintain PBJ Policy

Le Mars, Iowa Survey Completed on 04-17-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to meet staffing requirements in three metrics as identified through the CMS Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Quarter 1, 2025, which showed excessively low weekend staffing data. Despite nurses and CNAs being scheduled similarly for both weekdays and weekends, the reported data indicated discrepancies. The Director of Nursing (DON) and the Administrator both reviewed the PBJ data and acknowledged that incorrect information was reported, attributing the issue to a glitch at the main campus. Additionally, the Administrator stated that there was no existing policy regarding PBJ reporting at the facility. The facility reported a census of 57 residents during this period.

See complete original report
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