Based on policy review, Centers for Medicare & [and] Medicaid Services Electronic Staffing Data Submission Payroll-Based Journal Long-Term Care Facility Policy Manual review, Quarterly Payroll Based Journal (PBJ) review, facility staffing information review, and interview, the facility failed to submit accurate staffing data for Quarter 1 for PBJ 2026 (October 1, 2025- December 31, 2025) reviewed for staffing data. The findings include: 1. Review of the facility policy titled Policy & Procedure: PBJ Reporting, dated 10/1/2024, revealed To ensure all necessary staffing hours are submitted to the Centers for Medicare & Medicaid Services as required. …
F851 citations in Tennessee
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
Tennessee cites F851 more often than its own record predicts
2.65 times the share F851 takes of citations nationally.
Of every deficiency written in Tennessee 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 Tennessee surveyors wrote
F851 findings written in Tennessee, 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 review of the Certification and Survey Provider Enhanced Reporting (CASPER) Report Fiscal Year (FY) for the second Quarter of 2026 (January 1-March 31) review, daily staffing assignment review, time detail report review, and interviews the facility failed to submit accurate weekend staffing information to the Payroll Based Journal, (PBJ) for 13 of 13 weekends reviewed. The findings include: Review of the CASPER Report for the second quarter 2026 revealed, .Excessively Low Weekend Staffing .Triggered .Triggered = [equals] Submitted Weekend Staffing data is excessively low . …
The short window
Recent years
| Year | Share of Tennessee citations | vs expected |
|---|---|---|
| 2023 | 0.17% | 0.72× |
| 2024 | 0.37% | 1.25× |
| 2025 | 0.58% | 2.65× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Tennessee surveyors cite →
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