Based on record review and staff interviews, the facility failed to submit accurate payroll data on the Payroll Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS) related to failure to submit data for the quarter, which resulted in an indication of excessively low weekend staffing, no Registered Nurse (RN) hours, and failed to have licensed coverage 24 hours/day for Federal Fiscal Year (FY) 2025 Quarter 4 (July 1, 2025, through September 30, 2025)and Federal Fiscal Year 2026 Quarter 1 (October 1, 2025, through December 31, 2025). This was for 2 of 3 quarters reviewed for sufficient staffing.The findings included:The PBJ report for FY 2025 revealed for Quarter 4 (July 1, 2025, through September 30, 2025) there was no data submitted for the Quarter. …
F851 citations in North Carolina
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
North Carolina cites F851 more often than its own record predicts
1.78 times the share F851 takes of citations nationally.
Of every deficiency written in North Carolina 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 North Carolina surveyors wrote
F851 findings written in North Carolina, 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 Administrator interview, the facility failed to submit the Payroll Based Journal (PBJ) data for the 3rd, and 4th quarters in fiscal year (FY) 2022 and 1st quarter in fiscal year 2023. Findings included: Review of the Centers for Medicare and Medicaid Services (CMS) PBJ Staffing Data Report Certification and Survey Provider Enhanced Reports (CASPER Report 1705D) revealed no data was submitted for: - April 1 - June 30 (FY Quarter 3 2022) - July 1 - September 30 (FY Quarter 4 2022) - October 1 - December 31 (FY Quarter 1 2023) An interview with the Administrator on 5/23/23 at 2:30 PM revealed she was aware that the data had not been submitted. She stated she was responsible for submitting the staffing. …
The short window
Recent years
| Year | Share of North Carolina citations | vs expected |
|---|---|---|
| 2023 | 0.29% | 1.25× |
| 2024 | 0.16% | 0.54× |
| 2025 | 0.39% | 1.78× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else North Carolina surveyors cite →
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