Clinical Quality Indicators
Long-stay residents , lower is better
Antipsychotic medication use 18.07%Falls causing major injury 5.04%Pressure ulcers (high-risk) 3.69%Admissions Contacts
No admissions contacts on file yet.
CMS Star Ratings
Last inspected: May 2025 (395 days ago)🔍 Health Inspection
3/5
★★★☆☆
📊 Quality Measures
5/5
★★★★★
Medicare
Source: CMS MDS Quality Measures. Updated quarterly.
State avg: 35 min · US avg: 41 min
Total Nurse / Resident / Day
3h 23m
State avg: 3h 47m · US avg: 3h 53m
7 min
State avg: 5 min · US avg: 4 min
28 per 100
State avg: 50 per 100 · US avg: 46 per 100
Weekend Staffing (PBJ Q3 2024)
Weekend vs. Weekday RN
46%well below avg
US avg: 64%
Total Nurse Weekend
3h 14m
Federal Penalties
No federal penalties in the past 3 years.
✅ No penalty records on file
Inspection Citations
Survey: May 8, 2025(9 citations)
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
Survey: April 18, 2024(30 citations)
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
Survey: January 12, 2023(15 citations)
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for HarmAdministration Deficiencies
🟡 Potential for HarmEnvironmental Deficiencies
🟠 Actual HarmResident Rights DeficienciesComplaint
🟡 Potential for HarmQuality of Life and Care DeficienciesComplaint
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for Harm
15.0 per 100
State avg: 22.9 · US avg: 23.9
11.5 per 100
State avg: 13.2 · US avg: 12.0
5.0 per 100
State avg: 3.6 · US avg: 3.3
3.7 per 100
State avg: 6.0 · US avg: 5.1
0.0 per 100
State avg: 1.5 · US avg: 1.6
96.9 per 100
State avg: 78.1 · US avg: 79.7
Rates shown per 100 patients · Green = better than average · Amber = average · Red = below average
VBP Performance Score
31/100
Incentive Payment
-1.37% penalty
Healthcare-Assoc. Infections
7.6 per 100
Higher performance scores lead to payment bonuses. Lower scores indicate risk of readmission penalties.
Medicare Patients/Year
113
Avg Length of Stay
33.4 days
Avg Payment / Stay
$14,917.73
Patient Complexity
2.81 × 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)
🟡 Potential for HarmAdministration Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for HarmEnvironmental Deficiencies
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmAdministration Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for HarmEnvironmental Deficiencies
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmAdministration Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for HarmEnvironmental Deficiencies
Administration Deficiencies
🟡 Potential for HarmEnvironmental Deficiencies
🟠 Actual HarmResident Rights DeficienciesComplaint
🟡 Potential for HarmQuality of Life and Care DeficienciesComplaint
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for HarmAdministration Deficiencies
🟡 Potential for HarmEnvironmental Deficiencies
🟠 Actual HarmResident Rights DeficienciesComplaint
🟡 Potential for HarmQuality of Life and Care DeficienciesComplaint
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