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
3/5
📊 Quality Measures
5/5
RN / Resident / Day
40 min
State avg: 41 min · US avg: 41 min
LPN hrs/day
1h 3m
CNA hrs/day
1h 54m
Total Nurse / Resident / Day
3h 37m
State avg: 3h 51m · US avg: 3h 53m
PT / Resident / Day
13 min
State avg: 6 min · US avg: 4 min
RN Turnover Rate
33 per 100
State avg: 41 per 100 · US avg: 46 per 100
Weekend Staffing (PBJ Q3 2024)
RN Hours Weekday
50 min
RN Hours Weekend
43 min
Weekend vs. Weekday RN
88%above avg
US avg: 64%
Total Nurse Weekend
3h 13m
Federal Penalties
18 penalties · $210,042 total
| Date | Type | Fine | Denial Days |
|---|---|---|---|
| 7/10/2025 | Fine | $14,020 | - |
| 7/10/2025 | Fine | $14,020 | - |
| 7/10/2025 | Fine | $14,020 | - |
| 7/10/2025 | Fine | $14,020 | - |
| 7/10/2025 | Fine | $14,020 |
30-Day Readmission
17.1 per 100
State avg: 25.4 · US avg: 23.9
ED Visits (no readmit)
8.0 per 100
State avg: 8.2 · US avg: 12.0
VBP Performance Score
55/100
Incentive Payment
+0.99% bonus
Risk-Std Readmission
18.9 per 100
Healthcare-Assoc. Infections
6.1 per 100
Higher performance scores lead to payment bonuses. Lower scores indicate risk of readmission penalties.
Medicare Patients/Year
330
Avg Length of Stay
25.9 days
Avg Payment / Stay
$19,720.17
Patient Complexity
3.05 × 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)
| - |
| 7/10/2025 | Fine | $14,020 | - |
| 7/10/2025 | Fine | $14,020 | - |
| 7/10/2025 | Fine | $14,020 | - |
| 7/10/2025 | Fine | $14,020 | - |
| 11/19/2024 | Fine | $9,318 | - |
| 11/19/2024 | Fine | $9,318 | - |
| 11/19/2024 | Fine | $9,318 | - |
| 11/19/2024 | Fine | $9,318 | - |
| 11/19/2024 | Fine | $9,318 | - |
| 11/19/2024 | Fine | $9,318 | - |
| 11/19/2024 | Fine | $9,318 | - |
| 11/19/2024 | Fine | $9,318 | - |
| 11/19/2024 | Fine | $9,318 | - |
Inspection Citations
Survey: June 10, 2025(3 citations)
Survey: January 7, 2025(33 citations)
Survey: November 19, 2024(3 citations)
Survey: October 13, 2023(18 citations)
Survey: August 3, 2022(27 citations)
Falls w/ Major Injury
4.1 per 100
State avg: 2.4 · US avg: 3.3
Pressure Ulcers
7.6 per 100
State avg: 6.0 · US avg: 5.1
Antipsychotic Meds
2.1 per 100
State avg: 1.2 · US avg: 1.6
Flu Vaccination
98.0 per 100
State avg: 80.1 · 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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