F0851

F

Inaccurate PBJ Staffing Hours Reported to CMS

Oklahoma City, Oklahoma Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to accurately report direct care staffing hours to CMS through the Payroll-Based Journal (PBJ)/Quality of Care reporting system for specific dates in December 2025 and January 2026. For the 3 p.m. to 11 p.m. shift in December 2025, the Quality of Care report submitted to CMS showed significantly lower direct care staffing hours than those documented in the facility’s payroll detail report. On 12/20, with a census of 62, 52.32 hours were reported to CMS while payroll showed 91.51 hours; on 12/24, with a census of 63, 37.40 hours were reported while payroll showed 63.27 hours; on 12/27, with a census of 63, 61.18 hours were reported while payroll showed 86.99 hours; and on 12/28, with a census of 61, 61.00 hours were reported while payroll showed 98.69 hours.

A similar pattern occurred in January 2026 for the 3 p.m. to 11 p.m. shift, where the Quality of Care report again reflected inaccurate direct care staffing hours compared to the payroll detail. On 01/03, with a census of 65, 33.75 hours were reported versus 104.74 hours on payroll; on 01/20, with a census of 66, 38.21 hours were reported versus 64.10 hours; on 01/21, with a census of 66, 41.11 hours were reported versus 65.13 hours; on 01/24, with a census of 65, 72.50 hours were reported, which matched the payroll; on 01/27, with a census of 64, 37.83 hours were reported versus 75.80 hours; on 01/28, with a census of 64, 38.44 hours were reported versus 64.92 hours; and on 01/31, with a census of 64, 47.50 hours were reported versus 76.73 hours. During an interview on 02/18/26 at 12:05 p.m., the corporate nursing officer acknowledged that the facility had not accurately submitted staffing information to CMS. At the time, the administrator had identified that 63 residents resided in the facility.