CMS Stars
RN hrs / day
Trust Index
Bounce-back
Long-stay residents , lower is better
Source: CMS MDS Quality Measures. Updated quarterly.
โญ Overall
2/5
๐ Health Inspection
1/5
๐ฉโโ๏ธ Staffing
2/5
๐ Quality Measures
5/5
RN / Resident / Day
24 min
State avg: 41 min ยท US avg: 41 min
LPN hrs/day
55 min
CNA hrs/day
2h 16m
Total Nurse / Resident / Day
3h 34m
State avg: 3h 51m ยท US avg: 3h 53m
PT / Resident / Day
7 min
State avg: 6 min ยท US avg: 4 min
RN Turnover Rate
51 per 100
State avg: 41 per 100 ยท US avg: 46 per 100
Weekend Staffing (PBJ Q3 2024)
RN Hours Weekday
35 min
RN Hours Weekend
16 min
Weekend vs. Weekday RN
45%well below avg
US avg: 64%
Total Nurse Weekend
4h 38m
Federal Penalties
9 penalties ยท $923,940 total
| Date | Type | Fine | Denial Days |
|---|---|---|---|
| 7/19/2024 | Fine | $102,660 | - |
| 7/19/2024 | Fine | $102,660 | - |
| 7/19/2024 | Fine | $102,660 | - |
| 7/19/2024 | Fine | $102,660 | - |
| 7/19/2024 | Fine | $102,660 |
30-Day Readmission
30.0 per 100
State avg: 25.4 ยท US avg: 23.9
ED Visits (no readmit)
7.0 per 100
State avg: 8.2 ยท US avg: 12.0
VBP Performance Score
57/100
Incentive Payment
+1.21% bonus
Risk-Std Readmission
18.0 per 100
Healthcare-Assoc. Infections
4.7 per 100
Higher performance scores lead to payment bonuses. Lower scores indicate risk of readmission penalties.
Medicare Patients/Year
170
Avg Length of Stay
20.2 days
Avg Payment / Stay
$13,350.68
Patient Complexity
2.57 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)
| - |
| 7/19/2024 | Fine | $102,660 | - |
| 7/19/2024 | Fine | $102,660 | - |
| 7/19/2024 | Fine | $102,660 | - |
| 7/19/2024 | Fine | $102,660 | - |
Inspection Citations
Survey: February 10, 2025(3 citations)
Survey: July 19, 2024(42 citations)
Survey: November 15, 2022(9 citations)
Falls w/ Major Injury
1.2 per 100
State avg: 2.4 ยท US avg: 3.3
Pressure Ulcers
5.4 per 100
State avg: 6.0 ยท US avg: 5.1
Antipsychotic Meds
0.4 per 100
State avg: 1.2 ยท US avg: 1.6
Flu Vaccination
99.5 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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