CMS Stars
RN hrs / day
Trust Index
Bounce-back
Long-stay residents , lower is better
Source: CMS MDS Quality Measures. Updated quarterly.
⭐ Overall
3/5
🔍 Health Inspection
2/5
👩⚕️ Staffing
3/5
📊 Quality Measures
5/5
RN / Resident / Day
18 min
State avg: 41 min · US avg: 41 min
LPN hrs/day
1h 43m
CNA hrs/day
2h 41m
Total Nurse / Resident / Day
4h 41m
State avg: 3h 51m · US avg: 3h 53m
PT / Resident / Day
7 min
State avg: 6 min · US avg: 4 min
RN Turnover Rate
40 per 100
State avg: 41 per 100 · US avg: 46 per 100
Weekend Staffing (PBJ Q3 2024)
RN Hours Weekday
23 min
RN Hours Weekend
18 min
Weekend vs. Weekday RN
79%above avg
US avg: 64%
Total Nurse Weekend
4h 28m
Federal Penalties
9 penalties · $309,582 total
| Date | Type | Fine | Denial Days |
|---|---|---|---|
| 3/7/2025 | Fine | $34,398 | - |
| 3/7/2025 | Fine | $34,398 | - |
| 3/7/2025 | Fine | $34,398 | - |
| 3/7/2025 | Fine | $34,398 | - |
| 3/7/2025 | Fine | $34,398 |
30-Day Readmission
29.1 per 100
State avg: 25.4 · US avg: 23.9
ED Visits (no readmit)
8.4 per 100
State avg: 8.2 · US avg: 12.0
VBP Performance Score
27/100
Incentive Payment
-1.56% penalty
Risk-Std Readmission
23.0 per 100
Healthcare-Assoc. Infections
6.6 per 100
Higher performance scores lead to payment bonuses. Lower scores indicate risk of readmission penalties.
Medicare Patients/Year
179
Avg Length of Stay
29.0 days
Avg Payment / Stay
$18,368.84
Patient Complexity
2.77 × 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)
| - |
| 3/7/2025 | Fine | $34,398 | - |
| 3/7/2025 | Fine | $34,398 | - |
| 3/7/2025 | Fine | $34,398 | - |
| 3/7/2025 | Fine | $34,398 | - |
Inspection Citations
Survey: March 7, 2025(24 citations)
Survey: December 29, 2023(6 citations)
Survey: February 17, 2023(21 citations)
Falls w/ Major Injury
3.1 per 100
State avg: 2.4 · US avg: 3.3
Pressure Ulcers
5.2 per 100
State avg: 6.0 · US avg: 5.1
Antipsychotic Meds
0.7 per 100
State avg: 1.2 · US avg: 1.6
Flu Vaccination
96.8 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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