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F0851
F

Inaccurate PBJ Staffing Data Submission

Kenosha, Wisconsin Survey Completed on 07-24-2025

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 ensure that the mandatory staffing data submitted to CMS for the second quarter of 2025 was accurate and based on payroll and other verifiable and auditable data, as required. During a review of the Payroll-Based Journal (PBJ) staffing data, the facility was flagged for excessively low weekend staffing, which had the potential to affect all 90 residents. The facility's own assessment documented staffing needs and also triggered for low weekend staffing during the same period. However, upon review of nursing schedules and posted staff hours, no documented trends or gaps in weekend staff coverage were found. Interviews with the scheduler and the Director of Recruitment (DOR) revealed that the facility does not use agency staff and typically overstaffs on weekends to cover call-ins, with no reported staffing concerns. The DOR, responsible for submitting PBJ reports, stated that the system alerted them to being in the bottom 20th percentile for staffing, but did not investigate the cause of this alert, which affected all company facilities. The Nursing Home Administrator (NHA) was not aware of any staffing alerts or low weekend staffing. No further information was provided to explain why the submitted staffing data was inaccurate or did not align with verifiable records.

See complete original report
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