Failure to Accurately Report Weekend Staffing in PBJ Submission
Penalty
Fine: $37,177
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 submit accurate direct care staffing information to CMS for the Payroll Based Journal (PBJ) Staffing Data Report covering January 1st to March 31st, 2025. The PBJ report triggered for excessively low weekend staffing during this period. Upon review, it was determined that the facility's PBJ data submission did not include staffing agency staff who worked on weekends, despite the facility maintaining a census of 70 residents. The Administrator confirmed in an interview that the omission of agency staff led to the inaccurate reporting, and the Regional Director later submitted a PBJ report that did not reflect concerns, but the original deficiency remained due to the incomplete data submission.