CMS Stars
RN hrs / day
Trust Index
Bounce-back
Long-stay residents , lower is better
Source: CMS MDS Quality Measures. Updated quarterly.
โญ Overall
5/5
๐ Health Inspection
4/5
๐ฉโโ๏ธ Staffing
5/5
๐ Quality Measures
3/5
RN / Resident / Day
1h 2m
State avg: 1h 2m ยท US avg: 41 min
LPN hrs/day
55 min
CNA hrs/day
2h 14m
Total Nurse / Resident / Day
4h 11m
State avg: 4h 30m ยท US avg: 3h 53m
PT / Resident / Day
8 min
State avg: 9 min ยท US avg: 4 min
RN Turnover Rate
36 per 100
State avg: 42 per 100 ยท US avg: 46 per 100
Weekend Staffing (PBJ Q3 2024)
RN Hours Weekday
1h 11m
RN Hours Weekend
53 min
Weekend vs. Weekday RN
74%above avg
US avg: 64%
Total Nurse Weekend
3h 51m
Federal Penalties
18 penalties ยท $346,662 total
| Date | Type | Fine | Denial Days |
|---|---|---|---|
| 10/8/2025 | Fine | $22,925 | - |
| 10/8/2025 | Fine | $22,925 | - |
| 10/8/2025 | Fine | $22,925 | - |
| 10/8/2025 | Fine | $22,925 | - |
| 10/8/2025 | Fine | $22,925 |
30-Day Readmission
21.8 per 100
State avg: 21.5 ยท US avg: 23.9
ED Visits (no readmit)
9.3 per 100
State avg: 11.2 ยท US avg: 12.0
VBP Performance Score
28/100
Incentive Payment
-1.50% penalty
Risk-Std Readmission
22.2 per 100
Healthcare-Assoc. Infections
8.3 per 100
Higher performance scores lead to payment bonuses. Lower scores indicate risk of readmission penalties.
Medicare Patients/Year
111
Avg Length of Stay
24.9 days
Avg Payment / Stay
$12,921.83
Patient Complexity
2.77 ร avg
Avg LOS 15-30 days is typical for short-term rehab ยท Patient complexity = HCC risk score (1.0 = national average; higher = sicker patient mix)
| - |
| 10/8/2025 | Fine | $22,925 | - |
| 10/8/2025 | Fine | $22,925 | - |
| 10/8/2025 | Fine | $22,925 | - |
| 10/8/2025 | Fine | $22,925 | - |
| 11/1/2023 | Fine | $15,593 | - |
| 11/1/2023 | Fine | $15,593 | - |
| 11/1/2023 | Fine | $15,593 | - |
| 11/1/2023 | Fine | $15,593 | - |
| 11/1/2023 | Fine | $15,593 | - |
| 11/1/2023 | Fine | $15,593 | - |
| 11/1/2023 | Fine | $15,593 | - |
| 11/1/2023 | Fine | $15,593 | - |
| 11/1/2023 | Fine | $15,593 | - |
Inspection Citations
Survey: October 8, 2025(3 citations)
Survey: October 31, 2024(21 citations)
Survey: September 16, 2024(6 citations)
Survey: November 1, 2023(33 citations)
Falls w/ Major Injury
2.9 per 100
State avg: 3.2 ยท US avg: 3.3
Pressure Ulcers
2.3 per 100
State avg: 4.4 ยท US avg: 5.1
Antipsychotic Meds
1.7 per 100
State avg: 0.9 ยท US avg: 1.6
Flu Vaccination
50.0 per 100
State avg: 83.1 ยท US avg: 79.7
Discharge to Community
N/A
Functional Improvement
N/A
Rates shown per 100 patients ยท Green = better than average ยท Amber = average ยท Red = below average
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