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
3/5
๐ Quality Measures
5/5
RN / Resident / Day
16 min
State avg: 41 min ยท US avg: 41 min
LPN hrs/day
46 min
CNA hrs/day
2h 17m
Total Nurse / Resident / Day
3h 20m
State avg: 3h 51m ยท US avg: 3h 53m
PT / Resident / Day
2 min
State avg: 6 min ยท US avg: 4 min
RN Turnover Rate
34 per 100
State avg: 41 per 100 ยท US avg: 46 per 100
Weekend Staffing (PBJ Q3 2024)
RN Hours Weekday
22 min
RN Hours Weekend
19 min
Weekend vs. Weekday RN
89%above avg
US avg: 64%
Total Nurse Weekend
3h 12m
Federal Penalties
No federal penalties in the past 3 years.
| Date | Type | Fine | Denial Days |
|---|---|---|---|
| 4/11/2023 | Fine | $37,544 | - |
| 4/11/2023 | Payment Denial | - | 9 |
| 4/11/2023 | Fine | $37,544 | - |
| 4/11/2023 | Payment Denial | - | 9 |
| 4/11/2023 | Fine | $37,544 |
30-Day Readmission
33.1 per 100
State avg: 25.4 ยท US avg: 23.9
ED Visits (no readmit)
7.1 per 100
State avg: 8.2 ยท US avg: 12.0
VBP Performance Score
21/100
Incentive Payment
-1.74% penalty
Risk-Std Readmission
21.4 per 100
Healthcare-Assoc. Infections
9.4 per 100
Higher performance scores lead to payment bonuses. Lower scores indicate risk of readmission penalties.
Medicare Patients/Year
165
Avg Length of Stay
37.7 days
Avg Payment / Stay
$20,508.95
Patient Complexity
3.05 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)
| - |
| 4/11/2023 | Payment Denial | - | 9 |
| 4/11/2023 | Fine | $37,544 | - |
| 4/11/2023 | Payment Denial | - | 9 |
| 4/11/2023 | Fine | $37,544 | - |
| 4/11/2023 | Payment Denial | - | 9 |
| 4/11/2023 | Fine | $37,544 | - |
| 4/11/2023 | Payment Denial | - | 9 |
| 4/11/2023 | Fine | $37,544 | - |
| 4/11/2023 | Payment Denial | - | 9 |
| 4/11/2023 | Fine | $37,544 | - |
| 4/11/2023 | Payment Denial | - | 9 |
| 4/11/2023 | Fine | $37,544 | - |
| 4/11/2023 | Payment Denial | - | 9 |
Inspection Citations
Survey: April 17, 2025(51 citations)
Survey: December 27, 2023(3 citations)
Survey: April 11, 2023(63 citations)
Falls w/ Major Injury
1.1 per 100
State avg: 2.4 ยท US avg: 3.3
Pressure Ulcers
3.3 per 100
State avg: 6.0 ยท US avg: 5.1
Antipsychotic Meds
0.0 per 100
State avg: 1.2 ยท US avg: 1.6
Flu Vaccination
98.0 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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