Based on record review and staff interviews, the facility failed to electronically submit complete and accurate direct care staffing information.Specifically, the facility failed to submit to the Center for Medicare and Medicaid Services (CMS) the Payroll Based Journal (PBJ) for the quarter (10/1/25 to 12/31/25) due to an unrecognized coding error.Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 5/27/26 to 6/2/26, resulting in the deficiency being cited as past noncompliance with a correction date of 5/13/26.I. Record reviewThe CMS submission report, fiscal year quarter one, 2026 (10/1/25 to 12/31/25), revealed the facility failed to submit the required data for the quarter. …
F851 citations in Colorado
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
Colorado cites F851 less often than its own record predicts
0.52 times the national share — cited less often here than elsewhere.
Of every deficiency written in Colorado 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 Colorado surveyors wrote
F851 findings written in Colorado, 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.
The short window
Recent years
| Year | Share of Colorado citations | vs expected |
|---|---|---|
| 2023 | 0.08% | 0.37× |
| 2024 | 0.15% | 0.51× |
| 2025 | 0.11% | 0.52× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Colorado surveyors cite →
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