CMS Stars
RN hrs / day
Trust Index
Bounce-back
Long-stay residents , lower is better
Source: CMS MDS Quality Measures. Updated quarterly.
โญ Overall
1/5
๐ Health Inspection
1/5
๐ฉโโ๏ธ Staffing
2/5
๐ Quality Measures
4/5
RN / Resident / Day
40 min
State avg: 41 min ยท US avg: 41 min
LPN hrs/day
48 min
CNA hrs/day
1h 56m
Total Nurse / Resident / Day
3h 24m
State avg: 3h 51m ยท US avg: 3h 53m
PT / Resident / Day
3 min
State avg: 6 min ยท US avg: 4 min
RN Turnover Rate
29 per 100
State avg: 41 per 100 ยท US avg: 46 per 100
Weekend Staffing (PBJ Q3 2024)
RN Hours Weekday
45 min
RN Hours Weekend
41 min
Weekend vs. Weekday RN
92%above avg
US avg: 64%
Total Nurse Weekend
3h 18m
Federal Penalties
9 penalties ยท $240,120 total
| Date | Type | Fine | Denial Days |
|---|---|---|---|
| 6/12/2023 | Fine | $26,680 | - |
| 6/12/2023 | Fine | $26,680 | - |
| 6/12/2023 | Fine | $26,680 | - |
| 6/12/2023 | Fine | $26,680 | - |
| 6/12/2023 | Fine | $26,680 |
30-Day Readmission
27.1 per 100
State avg: 25.4 ยท US avg: 23.9
ED Visits (no readmit)
5.5 per 100
State avg: 8.2 ยท US avg: 12.0
VBP Performance Score
31/100
Incentive Payment
-1.38% penalty
Risk-Std Readmission
19.2 per 100
Healthcare-Assoc. Infections
7.4 per 100
Higher performance scores lead to payment bonuses. Lower scores indicate risk of readmission penalties.
Medicare Patients/Year
234
Avg Length of Stay
22.8 days
Avg Payment / Stay
$14,581.97
Patient Complexity
3.08 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)
| - |
| 6/12/2023 | Fine | $26,680 | - |
| 6/12/2023 | Fine | $26,680 | - |
| 6/12/2023 | Fine | $26,680 | - |
| 6/12/2023 | Fine | $26,680 | - |
Inspection Citations
Survey: April 25, 2025(24 citations)
Survey: November 22, 2023(24 citations)
Survey: June 12, 2023(27 citations)
Falls w/ Major Injury
1.0 per 100
State avg: 2.4 ยท US avg: 3.3
Pressure Ulcers
9.6 per 100
State avg: 6.0 ยท US avg: 5.1
Antipsychotic Meds
2.1 per 100
State avg: 1.2 ยท US avg: 1.6
Flu Vaccination
89.9 per 100
State avg: 80.1 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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