CMS Stars
RN hrs / day
Trust Index
Bounce-back
Long-stay residents , lower is better
Source: CMS MDS Quality Measures. Updated quarterly.
โญ Overall
3/5
๐ Health Inspection
4/5
๐ฉโโ๏ธ Staffing
1/5
๐ Quality Measures
4/5
RN / Resident / Day
23 min
State avg: 47 min ยท US avg: 41 min
LPN hrs/day
60 min
CNA hrs/day
2h 6m
Total Nurse / Resident / Day
3h 28m
State avg: 3h 54m ยท US avg: 3h 53m
PT / Resident / Day
7 min
State avg: 6 min ยท US avg: 4 min
RN Turnover Rate
55 per 100
State avg: 47 per 100 ยท US avg: 46 per 100
Weekend Staffing (PBJ Q3 2024)
RN Hours Weekday
27 min
RN Hours Weekend
18 min
Weekend vs. Weekday RN
68%โ avg
US avg: 64%
Total Nurse Weekend
4h 17m
Federal Penalties
No federal penalties in the past 3 years.
โ No penalty records on file
Inspection Citations
Survey: February 21, 2025(6 citations)
30-Day Readmission
20.9 per 100
State avg: 23.1 ยท US avg: 23.9
ED Visits (no readmit)
11.0 per 100
State avg: 9.8 ยท US avg: 12.0
VBP Performance Score
13/100
Incentive Payment
-1.89% penalty
Risk-Std Readmission
21.8 per 100
Healthcare-Assoc. Infections
7.1 per 100
Higher performance scores lead to payment bonuses. Lower scores indicate risk of readmission penalties.
Medicare Patients/Year
150
Avg Length of Stay
27.8 days
Avg Payment / Stay
$15,475.5
Patient Complexity
2.57 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: January 12, 2024(18 citations)
Survey: August 29, 2023(3 citations)
Survey: April 27, 2023(6 citations)
Survey: March 10, 2023(12 citations)
Falls w/ Major Injury
2.7 per 100
State avg: 3.2 ยท US avg: 3.3
Pressure Ulcers
3.3 per 100
State avg: 5.3 ยท US avg: 5.1
Antipsychotic Meds
0.0 per 100
State avg: 1.5 ยท US avg: 1.6
Flu Vaccination
43.7 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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