Encompass Health Lakeshore Rehabilitation Hospital


About the Facility

CMS Certification Number (CCN)
013025
Ownership Type
For Profit
CMS Region
Atlanta
Certification Date
Address
3800 Ridgeway Drive
Phone Number
(205) 868-2000

Facility Medical Condition Statistics

All other conditions
401
Brain disease or condition (non-traumatic)
161
Brain injury (traumatic)
47
Hip or femur fracture
202
Hip or knee replacement, amputation or other bone or joint condition
359
Nervous system disorder (excluding stroke)
358
Spinal cord disease or condition (non-traumatic)
37
Spinal cord injury (traumatic)
Data not available for this reporting period.
Stroke
237

Facility Quality of Patient Care Measures

Catheter-associated urinary tract infections (CAUTI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.387
SIR 95% confidence interval - upper limit
2.936
Comparative performance category
No Different than the National Benchmark
Catheter days
3,041
Predicted number of infections (B)
3.286
Number of infections reported (A)
4
SIR (A/B)
1.217
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
1,789
Denominator
1,789
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
14.7
Denominator
1,532
Average observed change score
14.5
Change in patients ability to move around
Average risk-adjusted change score
36.4
Denominator
1,532
Average observed change score
35.7
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
1,236
Denominator
1,532
Facility rate
80.7
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
1,190
Denominator
1,532
Facility rate
77.7
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
1
Denominator
1,789
Facility rate
0.1
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.273
SIR 95% confidence interval - upper limit
1.234
Comparative performance category
No Different than the National Benchmark
Patient days
31,892
Predicted number of infections (B)
11.217
Number of infections reported (A)
7
SIR (A/B)
0.624
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
458
Number of health care workers
567
Rate of flu vaccination
80.8
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
189
Number of eligible stays
1,764
Unadjusted potentially preventable readmission rate
10.71
Risk-standardized potentially preventable readmission rate (RSRR)
9.40
Lower limit of the 95% confidence interval on the RSRR
8.26
Upper limit of the 95% confidence interval on the RSRR
10.62
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
116
Number of eligible stays
1,988
Unadjusted potentially preventable readmission rate
5.84
Risk-standardized potentially preventable readmission rate (RSRR)
5.34
Lower limit of the 95% confidence interval on the RSRR
4.42
Upper limit of the 95% confidence interval on the RSRR
6.39
Comparative performance category
No Different than the National Rate
Rate of successful return to home or community from an IRF
Observed number of discharges to community (DTC)
1,050
Number of eligible stays
1,576
Observed discharge to community rate
66.62
Risk-standardized discharge to community rate
69.57
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
67.13
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
71.94
Comparative performance category
Better than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
0.99
Number of eligible episodes
1,839
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
1,784
Denominator
1,789
Facility rate
99.7
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
11
Denominator
1,786
Facility observed rate
0.6
Facility risk-adjusted rate
0.6
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
389
Number of health care workers
481
Rate of COVID-19 vaccination
80.9