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F0851
F

Inaccurate PBJ Submission Resulting in Underreported Weekend Staffing

El Dorado, Kansas Survey Completed on 04-09-2026

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 CMS through the Payroll Based Journal (PBJ) system as required, resulting in reported staffing levels that did not reflect actual staffing. CMS PBJ reports for Fiscal Year 2026 Quarter 1 and Fiscal Year 2025 Quarter 3 showed excessively low weekend staffing, indicating that the data submitted did not accurately capture direct care staff hours. During an interview, an administrative staff member acknowledged awareness of a problem and reported that the previous Business Office Manager had submitted the PBJ information incorrectly. The facility’s own PBJ F851 policy required submission of payroll data in a uniform CMS-specified format for all direct care staff, including community, agency, and contract staff, and required that the data distinguish between employees and contracted or agency staff, but this policy was not followed, leading to incomplete and inaccurate staffing information being reported.

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