CMS Stars
RN hrs / day
Trust Index
Bounce-back
Long-stay residents, lower is better
Source: CMS MDS Quality Measures. Updated quarterly.
⭐ Overall
2/5
🔍 Health Inspection
1/5
👩⚕️ Staffing
2/5
📊 Quality Measures
5/5
RN / Resident / Day
35 min
State avg: 1h 2m · US avg: 41 min
LPN hrs/day
52 min
CNA hrs/day
2h 5m
Total Nurse / Resident / Day
3h 32m
State avg: 4h 30m · US avg: 3h 53m
PT / Resident / Day
4 min
State avg: 9 min · US avg: 4 min
RN Turnover Rate
61 per 100
State avg: 42 per 100 · US avg: 46 per 100
Weekend Staffing (PBJ Q3 2024)
RN Hours Weekday
35 min
RN Hours Weekend
17 min
Weekend vs. Weekday RN
48%well below avg
US avg: 64%
Total Nurse Weekend
4h 30m
Federal Penalties
3 penalties · $99,184 total
| Date | Type | Fine | Denial Days |
|---|---|---|---|
| 11/15/2024 | Fine | $76,148 | - |
| 11/8/2023 | Fine | $7,443 | - |
| 11/8/2023 | Fine | $15,593 | - |
Inspection Citations
Survey: November 15, 2024(32 citations)
30-Day Readmission
20.5 per 100
State avg: 21.5 · US avg: 23.9
ED Visits (no readmit)
6.2 per 100
State avg: 11.2 · US avg: 12.0
VBP Performance Score
12/100
Incentive Payment
-1.90% penalty
Risk-Std Readmission
20.5 per 100
Healthcare-Assoc. Infections
8.3 per 100
Higher performance scores lead to payment bonuses. Lower scores indicate risk of readmission penalties.
Medicare Patients/Year
260
Avg Length of Stay
36.2 days
Avg Payment / Stay
$19,460.69
Patient Complexity
3.04 × 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)
Survey: November 8, 2023(23 citations)
Falls w/ Major Injury
3.8 per 100
State avg: 3.2 · US avg: 3.3
Pressure Ulcers
2.6 per 100
State avg: 4.4 · US avg: 5.1
Antipsychotic Meds
0.0 per 100
State avg: 0.9 · US avg: 1.6
Flu Vaccination
81.6 per 100
State avg: 83.1 · 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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