About the Facility
- CMS Certification Number (CCN)
- 03T010
- Ownership Type
- Non-profit
- CMS Region
- San Francisco
- Certification Date
- Address
1601 W. St. Mary's Road
- Phone Number
- (520) 872-6244
Facility Medical Condition Statistics
- All other conditions
- 58
- Brain disease or condition (non-traumatic)
- 16
- Brain injury (traumatic)
- Data not available for this reporting period.
- Hip or femur fracture
- 35
- Hip or knee replacement, amputation or other bone or joint condition
- 25
- Nervous system disorder (excluding stroke)
- 11
- Spinal cord disease or condition (non-traumatic)
- 17
- Spinal cord injury (traumatic)
- Data not available for this reporting period.
- Stroke
- 107
Facility Quality of Patient Care Measures
- Catheter-associated urinary tract infections (CAUTI)
- Standardized infection ratio (SIR) 95% confidence interval - lower limit
- Not Available
- SIR 95% confidence interval - upper limit
- Not Available
- Comparative performance category
- Not Available
- Catheter days
- 345
- Predicted number of infections (B)
- 0.939
- Number of infections reported (A)
- 0
- SIR (A/B)
- Not Available
- Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
- Numerator
- 271
- Denominator
- 272
- Facility rate
- 99.6
- Change in patients ability to care for themselves
- Average risk-adjusted change score
- 13.6
- Denominator
- 245
- Average observed change score
- 13.0
- Change in patients ability to move around
- Average risk-adjusted change score
- 26.8
- Denominator
- 245
- Average observed change score
- 25.3
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 172
- Denominator
- 245
- Facility rate
- 70.2
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 104
- Denominator
- 245
- Facility rate
- 42.4
- Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
- Numerator
- 0
- Denominator
- 272
- Facility rate
- 0.0
- Clostridium difficile Infection (CDI)
- Standardized infection ratio (SIR) 95% confidence interval - lower limit
- 0.028
- SIR 95% confidence interval - upper limit
- 2.768
- Comparative performance category
- No Different than the National Benchmark
- Patient days
- 4,498
- Predicted number of infections (B)
- 1.782
- Number of infections reported (A)
- 1
- SIR (A/B)
- 0.561
- Percentage of healthcare personnel who got a flu shot for the current season
- Number of health care workers vaccinated
- 75
- Number of health care workers
- 80
- Rate of flu vaccination
- 93.8
- Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
- Number of potentially preventable readmissions following discharge
- 18
- Number of eligible stays
- 336
- Unadjusted potentially preventable readmission rate
- 5.36
- Risk-standardized potentially preventable readmission rate (RSRR)
- 8.11
- Lower limit of the 95% confidence interval on the RSRR
- 6.34
- Upper limit of the 95% confidence interval on the RSRR
- 10.15
- Comparative performance category
- No Different than the National Rate
- Rate of potentially preventable hospital readmissions during the IRF stay
- Number of potentially preventable readmissions
- 9
- Number of eligible stays
- 360
- Unadjusted potentially preventable readmission rate
- 2.50
- Risk-standardized potentially preventable readmission rate (RSRR)
- 4.18
- Lower limit of the 95% confidence interval on the RSRR
- 2.72
- Upper limit of the 95% confidence interval on the RSRR
- 6.15
- 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)
- 221
- Number of eligible stays
- 288
- Observed discharge to community rate
- 76.74
- Risk-standardized discharge to community rate
- 71.07
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 67.04
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 74.71
- Comparative performance category
- Better than the National Rate
- Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
- MSPB score
- 0.92
- Number of eligible episodes
- 307
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 271
- Denominator
- 272
- Facility rate
- 99.6
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 3
- Denominator
- 269
- Facility observed rate
- 1.1
- Facility risk-adjusted rate
- 1.5
- Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
- Number of health care workers vaccinated
- 66
- Number of health care workers
- 78
- Rate of COVID-19 vaccination
- 84.6