Encompass Health Rehabilitation Hospital of Tustin


About the Facility

CMS Certification Number (CCN)
053034
Ownership Type
For Profit
CMS Region
San Francisco
Certification Date
Address
15120 Kensington Park Dr
Phone Number
(714) 832-9200

Facility Medical Condition Statistics

All other conditions
148
Brain disease or condition (non-traumatic)
74
Brain injury (traumatic)
59
Hip or femur fracture
70
Hip or knee replacement, amputation or other bone or joint condition
144
Nervous system disorder (excluding stroke)
199
Spinal cord disease or condition (non-traumatic)
65
Spinal cord injury (traumatic)
Data not available for this reporting period.
Stroke
244

Facility Quality of Patient Care Measures

Catheter-associated urinary tract infections (CAUTI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.576
SIR 95% confidence interval - upper limit
4.370
Comparative performance category
No Different than the National Benchmark
Catheter days
1,083
Predicted number of infections (B)
2.208
Number of infections reported (A)
4
SIR (A/B)
1.812
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
1,000
Denominator
1,001
Facility rate
99.9
Change in patients ability to care for themselves
Average risk-adjusted change score
14.4
Denominator
855
Average observed change score
14.8
Change in patients ability to move around
Average risk-adjusted change score
34.0
Denominator
855
Average observed change score
34.2
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
645
Denominator
855
Facility rate
75.4
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
590
Denominator
855
Facility rate
69.0
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
1
Denominator
1,001
Facility rate
0.1
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.168
SIR 95% confidence interval - upper limit
1.274
Comparative performance category
No Different than the National Benchmark
Patient days
18,265
Predicted number of infections (B)
7.573
Number of infections reported (A)
4
SIR (A/B)
0.528
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
1,566
Number of health care workers
1,991
Rate of flu vaccination
78.7
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
54
Number of eligible stays
760
Unadjusted potentially preventable readmission rate
7.11
Risk-standardized potentially preventable readmission rate (RSRR)
8.97
Lower limit of the 95% confidence interval on the RSRR
7.33
Upper limit of the 95% confidence interval on the RSRR
10.75
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
55
Number of eligible stays
870
Unadjusted potentially preventable readmission rate
6.32
Risk-standardized potentially preventable readmission rate (RSRR)
6.68
Lower limit of the 95% confidence interval on the RSRR
5.50
Upper limit of the 95% confidence interval on the RSRR
8.66
Comparative performance category
Worse than the National Rate
Rate of successful return to home or community from an IRF
Observed number of discharges to community (DTC)
486
Number of eligible stays
710
Observed discharge to community rate
68.45
Risk-standardized discharge to community rate
65.92
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
62.91
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
68.67
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
1.02
Number of eligible episodes
840
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
998
Denominator
1,001
Facility rate
99.7
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
1
Denominator
1,000
Facility observed rate
0.1
Facility risk-adjusted rate
0.1
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
359
Number of health care workers
421
Rate of COVID-19 vaccination
85.3