CMS Stars
RN hrs / day
Trust Index
Bounce-back
Long-stay residents , lower is better
Source: CMS MDS Quality Measures. Updated quarterly.
โญ Overall
5/5
๐ Health Inspection
4/5
๐ฉโโ๏ธ Staffing
3/5
๐ Quality Measures
5/5
RN / Resident / Day
36 min
State avg: 47 min ยท US avg: 41 min
LPN hrs/day
48 min
CNA hrs/day
1h 59m
Total Nurse / Resident / Day
3h 23m
State avg: 3h 54m ยท US avg: 3h 53m
PT / Resident / Day
4 min
State avg: 6 min ยท US avg: 4 min
RN Turnover Rate
35 per 100
State avg: 47 per 100 ยท US avg: 46 per 100
Weekend Staffing (PBJ Q3 2024)
RN Hours Weekday
34 min
RN Hours Weekend
27 min
Weekend vs. Weekday RN
79%above avg
US avg: 64%
Total Nurse Weekend
3h 8m
Federal Penalties
No federal penalties in the past 3 years.
โ No penalty records on file
Inspection Citations
Survey: August 6, 2025(3 citations)
30-Day Readmission
22.3 per 100
State avg: 23.1 ยท US avg: 23.9
ED Visits (no readmit)
10.9 per 100
State avg: 9.8 ยท US avg: 12.0
VBP Performance Score
28/100
Incentive Payment
-1.53% penalty
Risk-Std Readmission
19.5 per 100
Healthcare-Assoc. Infections
7.8 per 100
Higher performance scores lead to payment bonuses. Lower scores indicate risk of readmission penalties.
Medicare Patients/Year
214
Avg Length of Stay
24.9 days
Avg Payment / Stay
$13,087.1
Patient Complexity
3.18 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)
Survey: December 30, 2024(3 citations)
Survey: January 11, 2024(9 citations)
Survey: May 23, 2023(3 citations)
Survey: February 2, 2023(3 citations)
Falls w/ Major Injury
3.0 per 100
State avg: 3.2 ยท US avg: 3.3
Pressure Ulcers
5.0 per 100
State avg: 5.3 ยท US avg: 5.1
Antipsychotic Meds
1.1 per 100
State avg: 1.5 ยท US avg: 1.6
Flu Vaccination
75.5 per 100
State avg: 68.7 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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