CMS Stars
RN hrs / day
Trust Index
Bounce-back
Long-stay residents , lower is better
Source: CMS MDS Quality Measures. Updated quarterly.
⭐ Overall
3/5
🔍 Health Inspection
2/5
👩⚕️ Staffing
4/5
📊 Quality Measures
5/5
RN / Resident / Day
48 min
State avg: 1h 2m · US avg: 41 min
LPN hrs/day
40 min
CNA hrs/day
2h 10m
Total Nurse / Resident / Day
3h 38m
State avg: 4h 30m · US avg: 3h 53m
PT / Resident / Day
2 min
State avg: 9 min · US avg: 4 min
RN Turnover Rate
32 per 100
State avg: 42 per 100 · US avg: 46 per 100
Weekend Staffing (PBJ Q3 2024)
RN Hours Weekday
47 min
RN Hours Weekend
49 min
Weekend vs. Weekday RN
105%above avg
US avg: 64%
Total Nurse Weekend
3h 30m
Federal Penalties
9 penalties · $344,610 total
| Date | Type | Fine | Denial Days |
|---|---|---|---|
| 3/1/2024 | Fine | $38,290 | - |
| 3/1/2024 | Fine | $38,290 | - |
| 3/1/2024 | Fine | $38,290 | - |
| 3/1/2024 | Fine | $38,290 | - |
| 3/1/2024 | Fine | $38,290 |
30-Day Readmission
12.4 per 100
State avg: 21.5 · US avg: 23.9
ED Visits (no readmit)
5.3 per 100
State avg: 11.2 · US avg: 12.0
VBP Performance Score
43/100
Incentive Payment
-0.38% penalty
Risk-Std Readmission
17.6 per 100
Healthcare-Assoc. Infections
7.9 per 100
Higher performance scores lead to payment bonuses. Lower scores indicate risk of readmission penalties.
Medicare Patients/Year
79
Avg Length of Stay
27.0 days
Avg Payment / Stay
$13,858.05
Patient Complexity
2.79 × avg
Avg LOS 15-30 days is typical for short-term rehab · Patient complexity = HCC risk score (1.0 = national average; higher = sicker patient mix)
| - |
| 3/1/2024 | Fine | $38,290 | - |
| 3/1/2024 | Fine | $38,290 | - |
| 3/1/2024 | Fine | $38,290 | - |
| 3/1/2024 | Fine | $38,290 | - |
Inspection Citations
Survey: March 1, 2024(21 citations)
Survey: March 10, 2023(36 citations)
Falls w/ Major Injury
4.3 per 100
State avg: 3.2 · US avg: 3.3
Pressure Ulcers
1.9 per 100
State avg: 4.4 · US avg: 5.1
Antipsychotic Meds
0.6 per 100
State avg: 0.9 · US avg: 1.6
Flu Vaccination
85.4 per 100
State avg: 83.1 · US avg: 79.7
Discharge to Community
N/A
Functional Improvement
N/A
Rates shown per 100 patients · Green = better than average · Amber = average · Red = below average
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