CASCADIA HEALTHCARE · BOARD OF DIRECTORS · SEPTEMBER 15, 2026
Nursing Staffing &
Clinical Quality

49 Buildings. 90 Correlations. The Data Doesn't Lie.

49
Buildings
Analyzed
90
Correlation
Pairs Tested
5
Statistically
Significant (p<0.05)
4
Null Results
Reported Honestly

CMS PBJ Q4 2025  ·  CMS Five-Star Aug 2026  ·  MDS Quality Measures (4Q avg)  ·  Medicare Claims QMs
Analysis: Titan · Chief Intelligence Officer, JockiBox  ·  Statistical method: Pearson r, two-tailed p-values, 95% CI

CMS Payroll Based Journal Q4 2025 | CMS Five-Star Rating System Aug 2026 | MDS QM Dataset djen-97ju | Medicare Claims QM Dataset ijh5-nb2v1 / 14
THE BASELINE — WHERE WE STAND
The Portfolio Has a Staffing Crisis
53%
of buildings below the federal minimum
(0.55 RN PPD)
26 of 49 buildings  ·  CMS PBJ Q4 2025
69%
below the evidence-based 0.75 quality threshold
34 of 49 buildings
53%
Critical <0.50 PPD  ·  19 buildings
Low 0.50–0.75 PPD  ·  15 buildings
Marginal 0.75–1.00 PPD  ·  11 buildings
Adequate ≥1.00 PPD  ·  4 buildings
CMS PBJ Q4 2025 (4,508 daily records, 49 facilities) | Federal minimum 0.55: CMS-3442-F May 2024, repealed Dec 2025 | State floors active: WA, OR, ID, MT, AZ2 / 14
METHODOLOGY — EVERY NUMBER IS CITED
Four Public Data Sources. Zero Fabrication.
📋
CMS Payroll Based Journal
Q4 2025
4,508 daily records · 49 facilities
RN · LPN · CNA · Med Aide hours
Employee vs contractor breakdown
cms.gov/medicare/quality/nursing-home/staffing-data
⭐
CMS Five-Star Rating System
Aug 2026
49 buildings · CMS-adjusted PPD
RN Turnover % · Total Turnover %
Overall, Health, Staffing, QM stars
data.cms.gov · Five-Star Tech Guide 2024
📊
MDS Quality Measures
4-Quarter Avg
833 records · 46 buildings
Falls w/injury · Pressure ulcers · Restraints
Weight loss · ADL decline · UTI
CMS dataset djen-97ju · MDS 3.0 specs
🏥
Medicare Claims QMs
Risk-Adjusted
196 records · 44 buildings
Hospitalizations/1,000 LS days (551)
ED visits/1,000 LS days (552)
CMS dataset ijh5-nb2v · Claims methodology v3.0
Statistical method: Pearson r · Two-tailed p-values · 95% CI = ±1.96/√(n−3) · Significance: p<0.05 · n=28–46 per pair · Null results reported transparently
All datasets at data.cms.gov | PBJ per CMS Form CMS-671 | Analysis date: September 15, 20263 / 14
FINDING 1 — p = 0.047 ✓ STATISTICALLY SIGNIFICANT
RN Staffing Predicts Hospitalizations
−36%
fewer hospitalizations when
RN PPD crosses the 0.75 threshold
r = −0.378  ·  p = 0.047  ·  n = 28
95% CI: −0.671 to −0.005
Critical tier (<0.50 PPD) avg1.43 hosp/1,000
Marginal tier (0.75–1.00) avg0.91 hosp/1,000
Best — Stafholt (1.14 PPD)0.207 hosp/1,000
Worst — Cascadia of Boise3.18 hosp/1,000
Each dot = one building · color = PPD tier · teal line = trend
4.50.003.40.382.20.751.11.120.01.500.75COB 3.18Stafholt 0.207RN PPD (PBJ Q4 2025)Hosp/1,000 LS Daysr = -0.378p = 0.047
■ Critical■ Low■ Marginal■ Adequate
Outcome: CMS Medicare Claims QM 551 (Hospitalizations/1,000 LS days, risk-adjusted) | Staffing: CMS PBJ Q4 2025 | Pearson r, two-tailed t-test df=26 | n=28 buildings with Medicare Claims data4 / 14
FINDING 2 — p = 0.0015 ✓✓ STRONGEST SIGNAL IN STUDY
The Hidden Crisis: Malnutrition
−41%
lower weight loss rate when
RN PPD crosses 0.75
r = −0.454  ·  p = 0.0015  ·  n = 46  ·  STRONGEST MAGNITUDE
RNs perform nutritional assessments, identify early decline, and route to dietitians. Without licensed nurse coverage, weight loss goes undetected until it becomes a crisis. This is not a CNA function.
Critical tier (<0.50 PPD)6.43% weight loss
Marginal tier (0.75–1.00)3.79% weight loss
Adequate tier (≥1.00 PPD)2.77% weight loss
Best — Stafholt (1.14 PPD)2.77%
Weight loss rate by RN PPD tier
8.05.32.70.0Weight Loss %6.43Critical<0.505.93Low0.50-0.753.79Marginal0.75-1.002.77Adequate>=1.00
Outcome: CMS MDS QM 404 (Long-stay residents losing excessive weight, 4Q avg) | Staffing: CMS Five-Star Aug 2026 (CMS-adjusted RN PPD) | Pearson r, df=445 / 14
FINDING 3 — p = 0.0085 ✓✓ HIGHEST CORRELATION IN STUDY
Turnover is the #1 Driver of Emergency Visits
+149%
more emergency visits at
severe-turnover buildings
r = +0.487  ·  p = 0.0085  ·  n = 28  ·  HIGHEST r IN STUDY
High turnover destroys care continuity. Unfamiliar nurses miss the early warning signs that experienced staff catch before they become emergencies. Every retained RN is an ED prevention program.
Moderate turnover (20–40%)1.35 ED/1,000 days
Severe turnover (≥60%)3.37 ED/1,000 days
Portfolio avg RN turnover46.5%  (target: 20–30%)
Colville: 85.7% turnover5.35 ED/1,000 days
ED visits/1,000 LS days by RN Turnover tier
4.02.71.30.0ED Visits/1,000 LS Days1.67Low TO<20%1.35Moderate20-40%1.89High40-60%3.37Severe>=60%
Outcome: CMS Medicare Claims QM 552 (LS ED visits/1,000 days, risk-adjusted) | Turnover: CMS Five-Star Aug 2026 | Pearson r, df=266 / 14
FINDING 4 — p = 0.0054 ✓✓ SIGNIFICANT
Agency RNs Directly Predict Pressure Wounds
r = +0.404
Agency RN % predicts pressure ulcer rate
p = 0.0054  ·  n = 46 buildings
Turnover → Pressure Ulcers: r = +0.319, p = 0.031 also significant
Pressure ulcers are driven by continuity, not hours. Agency nurses don't know the high-risk residents. Consistent wound care nurses prevent ulcers — agency floats cannot replicate that institutional knowledge.
Colfax — 52.6% agency RN7.46% pressure ulcer rate
Coeur d'Alene — 28.9% agency RN6.28% ulcer rate
Mt. Ascension — 9.6% agency RN6.89% ulcer rate
Low turnover buildings avg2.18% ulcer rate
Pressure ulcer rate by RN Turnover tier
5.53.71.80.0Press. Ulcers %2.18Low TO<20%2.67Moderate20-40%4.12High40-60%4.03Severe>=60%
Outcome: CMS MDS QM 479 (Long-stay pressure ulcers, 4Q avg) | Agency%: CMS PBJ Q4 2025 (contractor/total hours) | Turnover: CMS Five-Star Aug 20267 / 14
FINDING 5 — HONEST SCIENCE · NULL RESULT
Falls Are NOT a Staffing-Volume Problem
r = 0.009
Falls vs RN PPD  ·  p = 0.951
NOT SIGNIFICANT — across all 4 staffing metrics tested
Staffing Driverr vs Fallsp-value
RN PPD (PBJ)+0.0090.951 — no signal
Total PPD (CMS)+0.0310.838 — no signal
RN Turnover %+0.0980.517 — no signal
Agency RN %+0.0490.748 — no signal
Restraints vs RN PPD−0.0870.565 — no signal
Curry Village (13.68% falls) and Colville (5.91%) will not improve by adding nurses. Protocol redesign + environment change + care culture. Different intervention entirely.
Falls rate by RN PPD tier — no consistent pattern
4.53.01.50.0Falls %2.64Critical<0.502.52Low0.50-0.753.12Marginal0.75-1.001.84Adequate>=1.00
No trend. Confirmed null. Protocol intervention required, not staffing.
Outcome: CMS MDS QM 410 (Falls w/ major injury, 4Q avg) | QM 409 (Physical restraints) | All staffing: PBJ Q4 2025 | Null results reported per standard scientific practice8 / 14
SYNTHESIS — THE QUALITY CLIFF
Every Key Metric Improves Across the Staffing Threshold
Critical <0.50Low 0.50-0.75Marginal 0.75-1.00Adequate >=1.00Hosp/1KED/1KWt.Loss%Falls%(null p=0.951)
Critical→Marginal
−36% hospitalizations
p=0.047
Critical→Marginal
−44% ED visits
p=0.0085
Critical→Marginal
−41% weight loss
p=0.0015
Falls:
No pattern
p=0.951 — null
PBJ Q4 2025 | Five-Star Aug 2026 | MDS QMs | Medicare Claims QMs | Falls null result at scale9 / 14
PORTFOLIO RISK DASHBOARD — IMMEDIATE ATTENTION REQUIRED
11 Buildings Where Staffing is Driving Patient Harm
Composite risk score: PPD tier + turnover tier + adverse outcomes  ·  Silverton: Active Special Focus Facility (SFF)
Silverton
PPD 0.257
TO 66.7%
ACTIVE SFF
ED/1,000
4.24
Cascadia of Boise
PPD 0.266
TO 50.0%
1★
Hosp/1,000
3.18
Lewiston TC
PPD 0.294
TO 55.6%
Press.Ulc
5.32%
Colville
PPD 0.524
TO 85.7%
ED/1,000
5.35
Mt. Ascension
PPD 0.502
TO 58.8%
Falls
7.69%
Curry Village
PPD 0.493
TO 44.4%
Falls
13.68%
Colfax
PPD 0.660
TO 60.0%
Press.Ulc
7.46%
Coeur d'Alene
PPD 0.459
TO 63.6%
Press.Ulc
6.28%
Paradise Creek
PPD 0.398
TO 75.0%
ED/1,000
3.26
Libby Care
PPD 0.370
TO 41.7%
Press.Ulc
4.82%
Creekside
PPD 0.383
TO 50.0%
Press.Ulc
4.88%
PBJ Q4 2025 | Five-Star Aug 2026 | MDS QMs | Medicare Claims QMs10 / 14
BENCHMARK STUDY — BEST IN FLEET
Stafholt Proves What Is Possible Within Our Own Portfolio
Stafholt Health & Rehabilitation
0.207
Hospitalizations per 1,000 LS days — best in portfolio
RN PPD: 1.14Wt Loss: 2.77%Rating: 4★
6.9×
Better
Critical Tier Average
(19 buildings, RN PPD <0.50)
1.43
Hospitalizations per 1,000 LS days
Avg PPD: 0.379Wt Loss: 6.43%Avg Rating: 2.8★
Alderwood Park  ·  RN PPD: 0.785  |  Hosp/1K: 0.625  |  5★ Overall
We don't need outside consultants to find the playbook. The answer is inside our own portfolio.
PBJ Q4 2025 (staffing) | Five-Star Aug 2026 (stars, turnover) | Medicare Claims QM 551 (hospitalizations) | MDS QM 404 (weight loss)11 / 14
FINANCIAL IMPACT — CONSERVATIVE ESTIMATE
$7,000,000
Annual cost of understaffing and high turnover — before PDPM losses, VBP penalties, or litigation
$1.7M
Avoidable Hospitalizations
120 events/yr · 36% reduction possible at 0.75 PPD · $14K avg cost/event
$0.6M
Avoidable ED Visits
203 visits/yr · 44% reduction possible · $3K avg cost/visit
$2.7M
RN Turnover Replacement
228 RNs replaced/yr · $12K avg recruiting, training, agency gap fill
$1.2M
Agency Premium Spread
7.2% avg agency RN · 15–20% premium over employee cost · 49 buildings
+more
VBP penalties · PDPM losses · Survey fines
Not included in this estimate
Hosp/ED based on 19 critical-tier buildings (204,962 LS patient-days/yr) reaching 0.75 PPD. Turnover: AHCA/NCAL 2024 Workforce Survey. VBP: FY2026 multipliers (Atlas −0.22%, Parker −0.26%, Wellington −0.29%).
Hosp/ED costs: CMS Medicare Claims QM differential x avg event cost | Turnover: AHCA/NCAL 2024 | Agency: PBJ Q4 2025 | VBP: CMS FY2026 final rule12 / 14
ACTION FRAMEWORK — EVIDENCE-INDEXED
30 · 90 · 180 Day Plan
30 DAYS
01
Emergency staffing huddle — 6 buildings. Silverton, COB, Lewiston, Colville, Mt. Ascension, Curry Village. CEO + DON + Will Merrick. Hosp rates 1.4–3.2× fleet avg.
r=−0.378, p=0.047
02
Silverton SFF triage. Active Special Focus Facility + lowest PPD (0.257) + 25.5% agency + 66.7% turnover. Physical intervention required this week.
Risk score 15/15 — highest in portfolio
03
Cascadia of Boise root cause. 3.18 hosp/1,000 is anomalous. Investigate discharge planning, care protocols, PDPM coding urgently.
2.2× portfolio average
90 DAYS
04
Set 0.75 RN PPD as operating floor. 34 buildings below. Build individualized hiring plans. Target: Critical→Marginal by Q2 2027.
−36% hosp · −44% ED · −41% weight loss
05
Agency reduction — pressure ulcer focus. Colfax (52.6%), Coeur d'Alene (28.9%), Libby (18%). Replace agency with consistent wound care nurses.
r=+0.404, p=0.0054
06
RN retention — 11 severe-turnover buildings. Colville (85.7%), Paradise Creek (75%), Coeur d'Alene (63.6%). Root cause + retention plan.
r=+0.487, p=0.0085 — highest correlation
180 DAYS
07
Fall prevention: protocols, not headcount. Falls uncorrelated with staffing (r=0.009, p=0.951). Curry Village (13.68%), Colville (5.91%) need protocol audit + environment redesign.
Null result — different intervention required
08
Nutrition surveillance for sub-0.75 buildings. RN-led daily weights + appetite monitoring. Weight loss rate halves at 0.75 threshold.
r=−0.454, p=0.0015 — strongest signal
09
Quarterly correlation refresh. Rebuild every PBJ quarter. Track tier movement. Feed to JockiBox KNOWLEDGE files.
This study = the baseline
All actions indexed to p<0.05 findings except #07 (null-result-driven protocol intervention)13 / 14
APPENDIX — FULL CORRELATION MATRIX
All 42 Correlations  ·  Gold Border = Statistically Significant (p < 0.05)
Hosp/1KED/1KPressUlcFallsWt.LossRestraintsADLRN PPD (PBJ)-0.38-0.33+0.14+0.01-0.25-0.09-0.09CMS RN PPD-0.37-0.15+0.19-0.04-0.45-0.09-0.11RN Turnover%+0.07+0.49+0.32+0.10-0.12+0.01+0.03Agency RN%+0.09+0.36+0.40+0.05+0.17-0.11+0.16Total PPD-0.04+0.10+0.20+0.03-0.13+0.02-0.33CNA PPD-0.06+0.28+0.22+0.24+0.33-0.01-0.11
■ Teal: Lower PPD → worse outcome (negative r)■ Red: Higher turnover/agency → worse outcome (positive r)■ Gold border: p < 0.05■ Near-zero: negligible
Significant (p<0.05): RN PPD→Hosp (r=−0.378) · CMS PPD→Wt.Loss (r=−0.454) · Turnover→ED (r=+0.487) · Turnover→PU (r=+0.319) · Agency→PU (r=+0.404) · Total PPD→ADL (r=−0.331) · CNA PPD→Wt.Loss (r=+0.331)
Pearson r | Two-tailed p-values | df=n-2 | n=28-46 per pair | PBJ Q4 2025 + Five-Star Aug 2026 + MDS QMs + Medicare Claims QMs14 / 14
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