CMS Stars
RN hrs / day
Trust Index
Bounce-back
Long-stay residents, lower is better
Source: CMS MDS Quality Measures. Updated quarterly.
⭐ Overall
3/5
🔍 Health Inspection
3/5
👩⚕️ Staffing
3/5
📊 Quality Measures
2/5
RN / Resident / Day
32 min
State avg: 47 min · US avg: 41 min
LPN hrs/day
57 min
CNA hrs/day
1h 52m
Total Nurse / Resident / Day
3h 21m
State avg: 3h 54m · US avg: 3h 53m
PT / Resident / Day
4 min
State avg: 6 min · US avg: 4 min
RN Turnover Rate
40 per 100
State avg: 47 per 100 · US avg: 46 per 100
Weekend Staffing (PBJ Q3 2024)
RN Hours Weekday
43 min
RN Hours Weekend
34 min
Weekend vs. Weekday RN
79%above avg
US avg: 64%
Total Nurse Weekend
3h 8m
Federal Penalties
3 penalties · $9,009 total
| Date | Type | Fine | Denial Days |
|---|---|---|---|
| 1/8/2024 | Fine | $2,659 | - |
| 1/2/2024 | Fine | $2,117 | - |
| 12/11/2023 | Fine | $4,233 | - |
Inspection Citations
Survey: September 26, 2025(5 citations)
30-Day Readmission
25.6 per 100
State avg: 23.1 · US avg: 23.9
ED Visits (no readmit)
13.9 per 100
State avg: 9.8 · US avg: 12.0
VBP Performance Score
26/100
Incentive Payment
-1.58% penalty
Risk-Std Readmission
20.8 per 100
Healthcare-Assoc. Infections
6.7 per 100
Higher performance scores lead to payment bonuses. Lower scores indicate risk of readmission penalties.
Medicare Patients/Year
71
Avg Length of Stay
25.2 days
Avg Payment / Stay
$12,283.3
Patient Complexity
2.73 × 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: June 5, 2025(1 citation)
Survey: September 6, 2024(7 citations)
Survey: July 15, 2024(1 citation)
Survey: October 6, 2023(6 citations)
Falls w/ Major Injury
0.7 per 100
State avg: 3.2 · US avg: 3.3
Pressure Ulcers
6.9 per 100
State avg: 5.3 · US avg: 5.1
Antipsychotic Meds
1.9 per 100
State avg: 1.5 · US avg: 1.6
Flu Vaccination
66.3 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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