Based on interview and record review, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) Quarter1 (October 1-December 31/2025), Quarter 2 (January 1-March 31), Quarter 3 (April 1-June 30, 2025), and Quarter 4 (July 1-September 30, 2025) indicated the facility had excessively low weekend nurse staffing. Review of the facility's weekend nursing schedules and working hours for the above Quarters revealed the facility had adequate staffing. On 08/18/25 at 08:26 AM, Administrative Staff A stated the administrator and corporate staff were responsible for submitting the PBJ. …
F851 citations in Kansas
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
Kansas cites F851 more often than its own record predicts
8.89 times the share F851 takes of citations nationally.
Of every deficiency written in Kansas 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 Kansas surveyors wrote
F851 findings written in Kansas, 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 and interview, the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ). Findings included:- The PBJ Staffing Data Report CASPER Report 1705D provided by the Centers for Medicaid and Medicare (CMS) for Fiscal Year (FY) 2026 Quarter (Q), Q2, and Q4 documented excessively low weekend staffing.Review of the facility's actual working schedule sheets from 02/11/2025 to 08/11/2026 revealed the facility maintained and had the same number of staff scheduled and worked as during the week: Two nurses for day shift, and two nurses for evening and night shift; six to eight nurse aides on day shift, and five to seven nurse aides on evening and four to five nurses' aides on night shift; and two… …
The short window
Recent years
| Year | Share of Kansas citations | vs expected |
|---|---|---|
| 2023 | 1.26% | 5.47× |
| 2024 | 2.48% | 8.47× |
| 2025 | 1.93% | 8.89× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Kansas surveyors cite →
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