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F0851
C

Failure to Accurately Submit Weekend Staffing Data via PBJ

Louisburg, Kansas Survey Completed on 08-26-2025

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 electronically submit complete and accurate direct care staffing information to the Federal regulatory agency through the Payroll-Based Journal (PBJ) system. Specifically, the facility did not accurately report hourly staffing data for all weekend personnel for multiple fiscal quarters. Although the PBJ Staffing Data Report indicated insufficient weekend staffing, a review of the nursing schedule and payroll data sheets for the same periods showed that the facility actually had sufficient staff coverage on weekends. During an interview, administrative staff confirmed that reported time was not accurately recorded in relation to staff scheduling, and that a half-hour was automatically deducted from each staff member's worked time for lunch by corporate policy. The facility's own policy requires timely and accurate submission of staffing data to CMS, but this was not followed, resulting in incomplete and inaccurate reporting for weekend staffing.

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