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
2/5
👩⚕️ Staffing
1/5
📊 Quality Measures
5/5
RN / Resident / Day
37 min
State avg: 1h 2m · US avg: 41 min
LPN hrs/day
1h 32m
CNA hrs/day
2h 24m
Total Nurse / Resident / Day
4h 33m
State avg: 4h 30m · US avg: 3h 53m
PT / Resident / Day
7 min
State avg: 9 min · US avg: 4 min
RN Turnover Rate
49 per 100
State avg: 42 per 100 · US avg: 46 per 100
Weekend Staffing (PBJ Q3 2024)
RN Hours Weekday
49 min
RN Hours Weekend
24 min
Weekend vs. Weekday RN
49%below avg
US avg: 64%
Total Nurse Weekend
4h 6m
Federal Penalties
4 penalties · $78,351 total
| Date | Type | Fine | Denial Days |
|---|---|---|---|
| 4/18/2025 | Fine | $52,305 | - |
| 4/18/2025 | Payment Denial | - | 5 |
| 10/17/2023 | Fine | $12,649 | - |
| 10/17/2023 | Fine | $13,397 | - |
| 2/23/2023 | Fine | $104,273 |
30-Day Readmission
19.5 per 100
State avg: 21.5 · US avg: 23.9
ED Visits (no readmit)
7.2 per 100
State avg: 11.2 · US avg: 12.0
VBP Performance Score
14/100
Incentive Payment
-1.87% penalty
Risk-Std Readmission
19.4 per 100
Healthcare-Assoc. Infections
8.8 per 100
Higher performance scores lead to payment bonuses. Lower scores indicate risk of readmission penalties.
Medicare Patients/Year
517
Avg Length of Stay
31.5 days
Avg Payment / Stay
$18,044.49
Patient Complexity
2.86 × 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)
| - |
Inspection Citations
Survey: April 18, 2025(6 citations)
Survey: February 17, 2025(3 citations)
Survey: March 21, 2024(7 citations)
Survey: October 17, 2023(6 citations)
Survey: February 23, 2023(9 citations)
Falls w/ Major Injury
1.5 per 100
State avg: 3.2 · US avg: 3.3
Pressure Ulcers
8.0 per 100
State avg: 4.4 · US avg: 5.1
Antipsychotic Meds
0.4 per 100
State avg: 0.9 · US avg: 1.6
Flu Vaccination
92.2 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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