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
3/5
👩⚕️ Staffing
4/5
📊 Quality Measures
3/5
RN / Resident / Day
53 min
State avg: 41 min · US avg: 41 min
LPN hrs/day
53 min
CNA hrs/day
2h 6m
Total Nurse / Resident / Day
3h 52m
State avg: 3h 51m · US avg: 3h 53m
PT / Resident / Day
6 min
State avg: 6 min · US avg: 4 min
RN Turnover Rate
28 per 100
State avg: 41 per 100 · US avg: 46 per 100
Weekend Staffing (PBJ Q3 2024)
RN Hours Weekday
52 min
RN Hours Weekend
38 min
Weekend vs. Weekday RN
73%above avg
US avg: 64%
Total Nurse Weekend
4h 3m
Federal Penalties
18 penalties · $44,442 total
| Date | Type | Fine | Denial Days |
|---|---|---|---|
| 10/10/2023 | Fine | $1,764 | - |
| 10/10/2023 | Fine | $1,764 | - |
| 10/10/2023 | Fine | $1,764 | - |
| 10/10/2023 | Fine | $1,764 | - |
| 10/10/2023 | Fine | $1,764 |
30-Day Readmission
26.0 per 100
State avg: 25.4 · US avg: 23.9
ED Visits (no readmit)
12.7 per 100
State avg: 8.2 · US avg: 12.0
VBP Performance Score
12/100
Incentive Payment
-1.89% penalty
Risk-Std Readmission
23.3 per 100
Healthcare-Assoc. Infections
8.5 per 100
Higher performance scores lead to payment bonuses. Lower scores indicate risk of readmission penalties.
Medicare Patients/Year
187
Avg Length of Stay
26.1 days
Avg Payment / Stay
$19,452.54
Patient Complexity
2.76 × 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)
| - |
| 10/10/2023 | Fine | $1,764 | - |
| 10/10/2023 | Fine | $1,764 | - |
| 10/10/2023 | Fine | $1,764 | - |
| 10/10/2023 | Fine | $1,764 | - |
| 9/18/2023 | Fine | $3,174 | - |
| 9/18/2023 | Fine | $3,174 | - |
| 9/18/2023 | Fine | $3,174 | - |
| 9/18/2023 | Fine | $3,174 | - |
| 9/18/2023 | Fine | $3,174 | - |
| 9/18/2023 | Fine | $3,174 | - |
| 9/18/2023 | Fine | $3,174 | - |
| 9/18/2023 | Fine | $3,174 | - |
| 9/18/2023 | Fine | $3,174 | - |
Inspection Citations
Survey: June 11, 2025(36 citations)
Survey: November 22, 2023(15 citations)
Falls w/ Major Injury
7.0 per 100
State avg: 2.4 · US avg: 3.3
Pressure Ulcers
5.5 per 100
State avg: 6.0 · US avg: 5.1
Antipsychotic Meds
0.7 per 100
State avg: 1.2 · US avg: 1.6
Flu Vaccination
95.0 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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