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
2/5
๐ฉโโ๏ธ Staffing
3/5
๐ Quality Measures
4/5
RN / Resident / Day
36 min
State avg: 41 min ยท US avg: 41 min
LPN hrs/day
24 min
CNA hrs/day
2h 17m
Total Nurse / Resident / Day
3h 18m
State avg: 3h 51m ยท US avg: 3h 53m
PT / Resident / Day
3 min
State avg: 6 min ยท US avg: 4 min
RN Turnover Rate
54 per 100
State avg: 41 per 100 ยท US avg: 46 per 100
Weekend Staffing (PBJ Q3 2024)
RN Hours Weekday
29 min
RN Hours Weekend
22 min
Weekend vs. Weekday RN
77%above avg
US avg: 64%
Total Nurse Weekend
5h 18m
Federal Penalties
No federal penalties in the past 3 years.
| Date | Type | Fine | Denial Days |
|---|---|---|---|
| 3/10/2023 | Fine | $5,000 | - |
| 3/10/2023 | Fine | $5,000 | - |
| 3/10/2023 | Fine | $5,000 | - |
| 3/10/2023 | Fine | $5,000 | - |
| 3/10/2023 | Fine | $5,000 |
30-Day Readmission
24.8 per 100
State avg: 25.4 ยท US avg: 23.9
ED Visits (no readmit)
5.6 per 100
State avg: 8.2 ยท US avg: 12.0
VBP Performance Score
35/100
Incentive Payment
-1.09% penalty
Risk-Std Readmission
18.9 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
182
Avg Length of Stay
29.0 days
Avg Payment / Stay
$16,641.29
Patient Complexity
2.88 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)
| - |
| 3/10/2023 | Fine | $5,000 | - |
| 3/10/2023 | Fine | $5,000 | - |
| 3/10/2023 | Fine | $5,000 | - |
| 3/10/2023 | Fine | $5,000 | - |
Inspection Citations
Survey: May 12, 2025(33 citations)
Survey: July 25, 2024(3 citations)
Survey: March 10, 2023(27 citations)
Falls w/ Major Injury
2.3 per 100
State avg: 2.4 ยท US avg: 3.3
Pressure Ulcers
3.8 per 100
State avg: 6.0 ยท US avg: 5.1
Antipsychotic Meds
2.5 per 100
State avg: 1.2 ยท US avg: 1.6
Flu Vaccination
77.2 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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