Based on record review, interview, and Payroll Based Journal (PBJ) Report, the facility failed to report accurate staffing data from January 01, 2026 - March 31, 2026, to the Centers for Medicare & Medicaid Services (CMS).This failure affected one quarter of data reviewed during the survey. Findings Include: The PBJ report generated for the quarter of 01/01/2026 through 03/31/2026 documented: . This Staffing Data Report identifies areas of concern that will be triggered . Metric .Excessively Low Weekend Staffing . Triggered = Submitted Weekend Staffing data is excessively low .On 06/25/2026 at 3:45 PM, during an interview, the Administrator (ADM) stated she was responsible for submitting staffing data to CMS. …
F851 citations in Alabama
Staffing data submission · Administration Deficiencies
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Alabama cites F851 more often than its own record predicts
4.59 times the share F851 takes of citations nationally.
Of every deficiency written in Alabama in 2025, this is the portion that was F851.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Alabama surveyors wrote
F851 findings written in Alabama, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on record review, interview, and Payroll Based Journal (PBJ) Report, the facility failed to report accurate staffing data from July 01, 2024 until September 30, 2024, to Centers for Medicare & Medicaid Services (CMS). This affected one quarter of data reviewed during the survey. Findings include: The PBJ report generated for the quarter of 07/01/2024 through 09/30/2024 documented: . This Staffing Data Report identifies areas of concern that will be triggered . Metric . Excessively Low Weekend Staffing . Triggered = Submitted Weekend Staffing data is excessively low . On 03/10/2025 at 11:37 AM, a review of PBJ report revealed it triggered for excessively low weekend staffing for the 4th quarter of 2024. …
The short window
Recent years
| Year | Share of Alabama citations | vs expected |
|---|---|---|
| 2023 | 1.04% | 4.50× |
| 2024 | 1.46% | 4.99× |
| 2025 | 0.99% | 4.59× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Alabama surveyors cite →
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