CMS Stars
RN hrs / day
Trust Index
Bounce-back
Long-stay residents , lower is better
Source: CMS MDS Quality Measures. Updated quarterly.
⭐ Overall
2/5
🔍 Health Inspection
1/5
👩⚕️ Staffing
3/5
📊 Quality Measures
5/5
RN / Resident / Day
43 min
State avg: 41 min · US avg: 41 min
LPN hrs/day
1h 21m
CNA hrs/day
2h 33m
Total Nurse / Resident / Day
4h 38m
State avg: 3h 51m · US avg: 3h 53m
PT / Resident / Day
7 min
State avg: 6 min · US avg: 4 min
RN Turnover Rate
90 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
29 min
Weekend vs. Weekday RN
56%below avg
US avg: 64%
Total Nurse Weekend
5h 44m
Federal Penalties
9 penalties · $2,912,130 total
| Date | Type | Fine | Denial Days |
|---|---|---|---|
| 8/21/2024 | Fine | $323,570 | - |
| 8/21/2024 | Fine | $323,570 | - |
| 8/21/2024 | Fine | $323,570 | - |
| 8/21/2024 | Fine | $323,570 | - |
| 8/21/2024 | Fine | $323,570 |
30-Day Readmission
24.4 per 100
State avg: 25.4 · US avg: 23.9
ED Visits (no readmit)
8.8 per 100
State avg: 8.2 · US avg: 12.0
VBP Performance Score
45/100
Incentive Payment
-0.19% penalty
Risk-Std Readmission
21.7 per 100
Healthcare-Assoc. Infections
6.8 per 100
Higher performance scores lead to payment bonuses. Lower scores indicate risk of readmission penalties.
Medicare Patients/Year
145
Avg Length of Stay
17.9 days
Avg Payment / Stay
$10,197.67
Patient Complexity
2.37 × 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)
| - |
| 8/21/2024 | Fine | $323,570 | - |
| 8/21/2024 | Fine | $323,570 | - |
| 8/21/2024 | Fine | $323,570 | - |
| 8/21/2024 | Fine | $323,570 | - |
Inspection Citations
Survey: August 21, 2024(30 citations)
Survey: March 7, 2024(3 citations)
Survey: December 12, 2022(12 citations)
Falls w/ Major Injury
3.3 per 100
State avg: 2.4 · US avg: 3.3
Pressure Ulcers
10.2 per 100
State avg: 6.0 · US avg: 5.1
Antipsychotic Meds
0.9 per 100
State avg: 1.2 · US avg: 1.6
Flu Vaccination
92.8 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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