Insufficient Weekend Staffing Documented by PBJ Reports
Penalty
Fine: $23,590
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 provide sufficient direct care staff to meet the needs of all residents on weekends during the first and second quarters of 2025. Payroll Based Journal (PBJ) reports and weekend staffing schedules revealed that there were 8 weekend days in the first quarter and 2 weekend days in the second quarter where the number of direct care staff was insufficient. The Center for Medicare & Medicaid Services (CMS) PBJ report indicated that the facility triggered for low weekend staffing during these periods. During an interview and review of the staffing records, the Market Clinical Advisor confirmed that the facility did not ensure enough staff were on duty to meet resident needs on weekends, as reflected in the PBJ reports.