Based on record review and interview, the facility failed to electronically submit direct care staffing data to Centers for Medicare and Medicaid Services (CMS) for the entire reporting period, Fiscal Year (FY) Quarter 1 2026 (October 1 - December 31) in accordance with the schedule specified by CMS.Findings include:The surveyor requested, but the facility was unable to provide, a policy regarding Payroll Based Journal (PBJ) reporting. Review of the PBJ Staffing Data Report, Fiscal Year Quarter 1 (October 1- December 31) indicated the following:-Failed to submit data for the quarter: Triggered.-One star staffing rating: Triggered.-Excessively Low Weekend Staffing: This metric is suppressed for this facility and quarter.-No RN (Registered Nurse) Hours: This metric is suppressed for this… …
F851 citations in Massachusetts
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
Massachusetts cites F851 more often than its own record predicts
1.25 times the share F851 takes of citations nationally.
Of every deficiency written in Massachusetts 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 Massachusetts surveyors wrote
F851 findings written in Massachusetts, 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 electronically submit complete and accurate direct care staffing data based on payroll to Centers for Medicare and Medicaid Services (CMS) for the entire reporting period, Fiscal Year (FY) Quarter 3 2024 (April 1 - June 30) as required by CMS. Findings include: Review of Reporting Direct Care Staffing Information (Payroll-Based Journal) (PBJ) Policy (undated) indicated but was not limited to the following: 1. Complete and accurate direct care staffing information is reported electronically to CMS through the PBJ system in a uniform format specified by CMS. 2. …
The short window
Recent years
| Year | Share of Massachusetts citations | vs expected |
|---|---|---|
| 2024 | 0.06% | 0.21× |
| 2025 | 0.27% | 1.25× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Massachusetts surveyors cite →
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