Based on review of facility documents, it was determined that the facility failed to submit direct care staffing information in the Payroll-Based Journal system for one of one quarter reviewed (Quarter 2). Findings Included:Review of the Payroll-Based Journal staffing data reports revealed that the facility failed to submit data for Quarter 2 (January 1, 2026, thru March 31, 2026).Interview with Administer E1 on July 23, 206 at 02:00 p.m. confirmed no further documented evidence of submission.28Pa Code 201.14(a) Responsibility of licensee
F851 citations in Pennsylvania
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
Pennsylvania cites F851 less often than its own record predicts
0.14 times the national share — cited less often here than elsewhere.
Of every deficiency written in Pennsylvania 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 Pennsylvania surveyors wrote
F851 findings written in Pennsylvania, 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 facility records and staff interview, it was determined that the facility failed to electronically submit direct care staffing information in the Payroll Based Journal (PBJ) system for one of one quarter reviewed. (Quarter one)Findings include:Review of a PBJ staffing data report revealed that the facility did not submit data for Quarter one (October 1, 2025, to December 31, 2025). In an interview on April 30, 2026, at 1:50 p.m., the Administrator confirmed that the facility failed to submit staffing data to the Center for Medicare and Medicaid Services (CMS) for the PBJ report for Quarter one of 2026.28 Pa. Code 201.18(b)(3) Management.
The short window
Recent years
| Year | Share of Pennsylvania citations | vs expected |
|---|---|---|
| 2024 | 0.08% | 0.27× |
| 2025 | 0.03% | 0.14× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Pennsylvania surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction