CMS Stars
RN hrs / day
Trust Index
Bounce-back
Long-stay residents , lower is better
Source: CMS MDS Quality Measures. Updated quarterly.
โญ Overall
3/5
๐ Health Inspection
4/5
๐ฉโโ๏ธ Staffing
1/5
๐ Quality Measures
2/5
RN / Resident / Day
31 min
State avg: 41 min ยท US avg: 41 min
LPN hrs/day
1h 17m
CNA hrs/day
1h 23m
Total Nurse / Resident / Day
3h 12m
State avg: 3h 51m ยท US avg: 3h 53m
PT / Resident / Day
6 min
State avg: 6 min ยท US avg: 4 min
RN Turnover Rate
44 per 100
State avg: 41 per 100 ยท US avg: 46 per 100
Weekend Staffing (PBJ Q3 2024)
RN Hours Weekday
37 min
RN Hours Weekend
18 min
Weekend vs. Weekday RN
50%below avg
US avg: 64%
Total Nurse Weekend
3h 36m
Federal Penalties
No federal penalties in the past 3 years.
โ No penalty records on file
Inspection Citations
Survey: July 18, 2025(3 citations)
30-Day Readmission
29.7 per 100
State avg: 25.4 ยท US avg: 23.9
ED Visits (no readmit)
8.6 per 100
State avg: 8.2 ยท US avg: 12.0
VBP Performance Score
22/100
Incentive Payment
-1.73% penalty
Risk-Std Readmission
18.9 per 100
Healthcare-Assoc. Infections
10.8 per 100
Higher performance scores lead to payment bonuses. Lower scores indicate risk of readmission penalties.
Medicare Patients/Year
120
Avg Length of Stay
33.7 days
Avg Payment / Stay
$27,486.52
Patient Complexity
3.91 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)
Survey: September 10, 2024(6 citations)
Survey: May 24, 2024(15 citations)
Survey: September 26, 2023(3 citations)
Survey: February 23, 2022(21 citations)
Falls w/ Major Injury
4.0 per 100
State avg: 2.4 ยท US avg: 3.3
Pressure Ulcers
13.0 per 100
State avg: 6.0 ยท US avg: 5.1
Antipsychotic Meds
3.2 per 100
State avg: 1.2 ยท US avg: 1.6
Flu Vaccination
86.0 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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