Staffing
CMS publishes a 4-star staffing rating for this facility.
RN staffing was 0.83 hours per resident day in 2026Q1, calculated from CMS PBJ records.
View staffing evidenceAsk Trust Hub Network
CMS overview
No proprietary TrustHub score. These ratings are published separately by CMS.
Facility information
CMS remains the primary federal record. Public website and additional contact details appear only when independently verified.
Decision guide
Factual evidence to examine before you decide. These summaries are not a score or recommendation.
CMS publishes a 4-star staffing rating for this facility.
RN staffing was 0.83 hours per resident day in 2026Q1, calculated from CMS PBJ records.
View staffing evidenceThe latest standard inspection on Mar 5, 2026 cited 15 deficiencies.
View inspection evidenceCMS-published records list 18 ownership or control parties.
View ownership evidenceCMS groups this facility with a chain covering 9 facilities across 3 states or territories.
View chain evidenceOwnership & operation
Operator, licensee, owner, manager, and chain stay separate. A connected organization is not automatically the party that runs daily operations.
SeniorTrustHub found evidence connecting this facility to:
6 currently connected nursing homes share this CMS organization identity with CHRISTINA JAYNE PENN MANAGEMENT TRUST.
These figures summarize currently connected CMS-certified nursing homes. Some facilities have incomplete measures; missing values are omitted, not treated as zero. Ownership structures can change. State operator or licensee evidence may differ from CMS ownership disclosures.
Ownership
These are CMS-published ownership disclosures. Medicare enrollment ownership and managerial-control information is reported by enrolled providers through CMS forms; it is not an independent determination of beneficial ownership.
Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Nov 1, 2010
Other facilities connected through this exact CMS organization identity: 0 across WI.
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Jun 1, 2015
Individual · CORPORATE OFFICER
Association date reported to CMS: May 1, 2021
Individual · CORPORATE OFFICER
Association date reported to CMS: Apr 15, 1994
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: May 1, 2021
Organization · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Aug 1, 1989
Other facilities connected through this exact CMS organization identity: 0 across WI.
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Apr 16, 2020
Individual · W-2 MANAGING EMPLOYEE
Association date reported to CMS: Sep 16, 2015
Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Nov 1, 2010
Other facilities connected through this exact CMS organization identity: 5 across MT, WI.
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Jun 1, 2015
Individual · CORPORATE OFFICER
Published ownership percentage: 15%
Association date reported to CMS: May 1, 2021
Individual · CORPORATE OFFICER
Published ownership percentage: 15%
Association date reported to CMS: Apr 15, 1994
Individual · OPERATIONAL/MANAGERIAL CONTROL
Published ownership percentage: 5%
Association date reported to CMS: May 1, 2021
Organization · OPERATIONAL/MANAGERIAL CONTROL
Published ownership percentage: 100%
Association date reported to CMS: Aug 1, 1989
Other facilities connected through this exact CMS organization identity: 6 across IN, MT, WI.
Individual · OPERATIONAL/MANAGERIAL CONTROL
Published ownership percentage: 20%
Association date reported to CMS: Apr 16, 2020
Individual · OTHER
Published ownership percentage: 100%
Association date reported to CMS: Jun 1, 2015
Individual · W-2 MANAGING EMPLOYEE
Published ownership percentage: 50%
Association date reported to CMS: Sep 16, 2015
Organization · Medicare-enrolled legal organization
Other facilities connected through this exact CMS organization identity: 0 across WI.
Roles are shown as CMS publishes them. Different CMS sources can describe different enrollment, ownership, and control concepts, so TrustHub keeps each source-specific disclosure distinct.
Chain context
Chain-level values describe this CMS-defined group, not any one facility. CMS Chain ID 605 is a grouping identifier, not a legal organization.
| Month | Facilities | Overall rating | Staffing rating |
|---|---|---|---|
| Wed Jul | 9 | 3.1 | 3.6 |
| Mon Jun | 9 | 3.6 | 3.7 |
| Fri May | 9 | 3.9 | 3.7 |
| Wed Apr | 9 | 3.8 | 3.7 |
| Sun Mar | 9 | 3.9 | 3.6 |
| Sun Feb | 9 | 4 | 3.6 |
Nursing Home Chain Performance Measures, fixed version da2db00a-0f3d-40a9-a535-588ff1220c55. Membership comes separately from CMS Skilled Nursing Facility Enrollments.
View official CMS sourceInspections & deficiencies
Scope and severity terms below are CMS classifications. They are not a TrustHub score.
No health-deficiency rows were deterministically linked to this inspection.
No health-deficiency rows were deterministically linked to this inspection.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 3, 2026)
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 3, 2026)
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 3, 2026)
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 3, 2026)
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 3, 2026)
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 3, 2026)
Provide enough food/fluids to maintain a resident's health.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 3, 2026)
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 3, 2026)
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 3, 2026)
Provide medically-related social services to help each resident achieve the highest possible quality of life.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 3, 2026)
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 3, 2026)
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 3, 2026)
Provide and implement an infection prevention and control program.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 3, 2026)
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 3, 2026)
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 3, 2026)
No health-deficiency rows were deterministically linked to this inspection.
No health-deficiency rows were deterministically linked to this inspection.
Ensure each resident receives an accurate assessment.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 18, 2024)
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 18, 2024)
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 18, 2024)
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 18, 2024)
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 18, 2024)
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 4, 2024)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 18, 2024)
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 18, 2024)
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 29, 2023)
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 29, 2023)
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 29, 2023)
No health-deficiency rows were deterministically linked to this inspection.
No health-deficiency rows were deterministically linked to this inspection.
Reasonably accommodate the needs and preferences of each resident.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Sep 24, 2023)
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Sep 24, 2023)
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Sep 24, 2023)
Plan the resident's discharge to meet the resident's goals and needs.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Sep 24, 2023)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Sep 24, 2023)
Implement a program that monitors antibiotic use.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Sep 24, 2023)
Penalties & enforcement
No penalty records were found for this provider in the currently loaded CMS Penalties dataset.
Questions to ask
Facility history
9 historical events available. Dates and values come from published CMS and official state regulator evidence, not a score.
15 deficiencies were recorded. That includes 1 higher-severity deficiency.
CMS · Recorded event date · View related evidence
No linked health-deficiency findings were recorded for this survey.
CMS · Recorded event date · View related evidence
Total nurse staffing increased from 3.19 to 3.58 hours per resident day between 2025Q3 and 2025Q4. Staffing improved across those reported periods.
3.19 → 3.58
CMS · Reported in a source release · View related evidence
RN staffing increased from 0.59 to 0.78 hours per resident day between 2025Q3 and 2025Q4. Staffing improved across those reported periods.
0.59 → 0.78
CMS · Reported in a source release · View related evidence
8 deficiencies were recorded.
CMS · Recorded event date · View related evidence
No linked health-deficiency findings were recorded for this survey.
CMS · Recorded event date · View related evidence
3 deficiencies were recorded.
CMS · Recorded event date · View related evidence
No linked health-deficiency findings were recorded for this survey.
CMS · Recorded event date · View related evidence
6 deficiencies were recorded.
CMS · Recorded event date · View related evidence
Staffing
CMS staffing rating: 4 of 5 stars. CMS calculates that rating separately using its published methodology. The values below are calculations from daily PBJ records for 2026Q1 (current source quarter).
| Measure | Monday–Friday | Saturday–Sunday |
|---|---|---|
| Total nursing | 3.863 | 3.209 |
| RN categories | 0.952 | 0.542 |
Contract staff accounted for 0% of reported nursing hours included in this quarter calculation.
Reported RN-category hours per resident day were 0.057 higher than the prior loaded quarter.
Solid bar: Total nursing · Outlined bar: RN categories
| Quarter | Total nursing | RN categories | LPN/LVN | CNA | Contract share | Days |
|---|---|---|---|---|---|---|
| 2025Q2 | 3.211 | 0.519 | 0.882 | 1.81 | 0% | 91 |
| 2025Q3 | 3.19 | 0.588 | 0.751 | 1.851 | 0.5% | 92 |
| 2025Q4 | 3.578 | 0.777 | 0.707 | 2.094 | 0% | 92 |
| 2026Q1 | 3.675 | 0.834 | 0.694 | 2.147 | 0% | 90 |
Hours-per-resident-day values are calculated by this platform from CMS-published daily PBJ hours and MDS census. For each displayed period, included hours are summed and divided by the summed census for days with a positive census. They are not CMS case-mix-adjusted staffing measures or a staffing rating.
View official CMS PBJ sourceWhat we can verify today
These measures come from the current successfully ingested CMS Nursing Home Provider Information release.
Planned evidence layers
These areas require separate authoritative CMS datasets. No findings are shown until those sources are ingested and reviewed.
Trust participation
Claims, corrections, and factual context are free. Submissions never replace CMS evidence or affect ranking.
Source register
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