Based on interview and record review, the facility did not ensure accurate reporting of the mandatory submission of staffing information based on payroll data to the Centers for Medicare & Medicaid Services (CMS). This has the potential to affect all 43 residents that reside in the facility.The facility failed to enter accurate data in their Payroll Based Journal (PBJ) reporting and triggered for three fiscal year quarters for excessively low weekend staffing and for one fiscal year quarter for one star staffing rating, and no Registered Nurse (RN) hours.Evidenced by:The facility's Payroll Based Journal policy, dated as revised 2/2026, states, in part: Policy: It is the policy of this facility to electronically submit timely to CMS complete and accurate direct care staffing information,… …
F851 citations in Wisconsin
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
Wisconsin cites F851 more often than its own record predicts
2.52 times the share F851 takes of citations nationally.
Of every deficiency written in Wisconsin 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 Wisconsin surveyors wrote
F851 findings written in Wisconsin, 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 interview and record review, the facility did not ensure it completed accurate mandatory submission of staffing information based on payroll data in a uniform electronic format to the Centers for Medicare & Medicaid Services (CMS). This had the potential to affect all 56 residents residing in the facility.Staffing information for Quarter 2 (January 1 - March 31) of the Payroll Based Journal (PBJ) was not accurately submitted to CMS. Findings include: The CMS Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated June 2022, indicates: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. …
The short window
Recent years
| Year | Share of Wisconsin citations | vs expected |
|---|---|---|
| 2023 | 0.50% | 2.17× |
| 2024 | 0.80% | 2.75× |
| 2025 | 0.55% | 2.52× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Wisconsin 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