CMS Stars
RN hrs / day
Trust Index
Bounce-back
Long-stay residents , lower is better
Source: CMS MDS Quality Measures. Updated quarterly.
⭐ Overall
1/5
🔍 Health Inspection
1/5
👩⚕️ Staffing
3/5
📊 Quality Measures
4/5
RN / Resident / Day
18 min
State avg: 41 min · US avg: 41 min
LPN hrs/day
49 min
CNA hrs/day
1h 50m
Total Nurse / Resident / Day
2h 56m
State avg: 3h 51m · US avg: 3h 53m
PT / Resident / Day
4 min
State avg: 6 min · US avg: 4 min
RN Turnover Rate
36 per 100
State avg: 41 per 100 · US avg: 46 per 100
Weekend Staffing (PBJ Q3 2024)
RN Hours Weekday
19 min
RN Hours Weekend
15 min
Weekend vs. Weekday RN
81%above avg
US avg: 64%
Total Nurse Weekend
2h 56m
Federal Penalties
9 penalties · $2,969,190 total
| Date | Type | Fine | Denial Days |
|---|---|---|---|
| 7/29/2024 | Fine | $329,910 | - |
| 7/29/2024 | Fine | $329,910 | - |
| 7/29/2024 | Fine | $329,910 | - |
| 7/29/2024 | Fine | $329,910 | - |
| 7/29/2024 | Fine | $329,910 |
30-Day Readmission
29.7 per 100
State avg: 25.4 · US avg: 23.9
ED Visits (no readmit)
12.3 per 100
State avg: 8.2 · US avg: 12.0
VBP Performance Score
48/100
Incentive Payment
+0.21% bonus
Risk-Std Readmission
17.4 per 100
Healthcare-Assoc. Infections
8.1 per 100
Higher performance scores lead to payment bonuses. Lower scores indicate risk of readmission penalties.
Medicare Patients/Year
131
Avg Length of Stay
39.0 days
Avg Payment / Stay
$21,157.95
Patient Complexity
3.27 × 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)
| - |
| 7/29/2024 | Fine | $329,910 | - |
| 7/29/2024 | Fine | $329,910 | - |
| 7/29/2024 | Fine | $329,910 | - |
| 7/29/2024 | Fine | $329,910 | - |
Inspection Citations
Survey: June 16, 2025(33 citations)
Survey: May 27, 2025(12 citations)
Survey: August 1, 2024(6 citations)
Survey: July 29, 2024(21 citations)
Survey: December 22, 2023(30 citations)
Falls w/ Major Injury
0.8 per 100
State avg: 2.4 · US avg: 3.3
Pressure Ulcers
5.8 per 100
State avg: 6.0 · US avg: 5.1
Antipsychotic Meds
2.5 per 100
State avg: 1.2 · US avg: 1.6
Flu Vaccination
92.2 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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