CMS Stars
RN hrs / day
Trust Index
Bounce-back
Long-stay residents, lower is better
Source: CMS MDS Quality Measures. Updated quarterly.
⭐ Overall
4/5
🔍 Health Inspection
3/5
👩⚕️ Staffing
5/5
📊 Quality Measures
3/5
RN / Resident / Day
1h 38m
State avg: 47 min · US avg: 41 min
LPN hrs/day
24 min
CNA hrs/day
2h 46m
Total Nurse / Resident / Day
4h 49m
State avg: 3h 54m · US avg: 3h 53m
PT / Resident / Day
5 min
State avg: 6 min · US avg: 4 min
RN Turnover Rate
35 per 100
State avg: 47 per 100 · US avg: 46 per 100
Weekend Staffing (PBJ Q3 2024)
RN Hours Weekday
1h 27m
RN Hours Weekend
1h 8m
Weekend vs. Weekday RN
78%above avg
US avg: 64%
Total Nurse Weekend
4h 26m
Federal Penalties
9 penalties · $122,175 total
| Date | Type | Fine | Denial Days |
|---|---|---|---|
| 5/10/2024 | Fine | $13,575 | - |
| 5/10/2024 | Fine | $13,575 | - |
| 5/10/2024 | Fine | $13,575 | - |
| 5/10/2024 | Fine | $13,575 | - |
| 5/10/2024 | Fine | $13,575 |
30-Day Readmission
25.3 per 100
State avg: 23.1 · US avg: 23.9
ED Visits (no readmit)
8.4 per 100
State avg: 9.8 · US avg: 12.0
VBP Performance Score
54/100
Incentive Payment
+0.86% bonus
Risk-Std Readmission
19.9 per 100
Healthcare-Assoc. Infections
6.3 per 100
Higher performance scores lead to payment bonuses. Lower scores indicate risk of readmission penalties.
Medicare Patients/Year
96
Avg Length of Stay
14.5 days
Avg Payment / Stay
$6,974.19
Patient Complexity
1.89 × 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)
| - |
| 5/10/2024 | Fine | $13,575 | - |
| 5/10/2024 | Fine | $13,575 | - |
| 5/10/2024 | Fine | $13,575 | - |
| 5/10/2024 | Fine | $13,575 | - |
Inspection Citations
Survey: June 18, 2025(33 citations)
Survey: October 2, 2024(3 citations)
Survey: July 31, 2024(6 citations)
Survey: August 24, 2023(6 citations)
Falls w/ Major Injury
1.9 per 100
State avg: 3.2 · US avg: 3.3
Pressure Ulcers
8.3 per 100
State avg: 5.3 · US avg: 5.1
Antipsychotic Meds
0.9 per 100
State avg: 1.5 · US avg: 1.6
Flu Vaccination
65.5 per 100
State avg: 68.7 · 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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