Leon S Peters Rehabilation


About the Facility

CMS Certification Number (CCN)
05T060
Ownership Type
Non-profit
CMS Region
San Francisco
Certification Date
Address
2823 Fresno St
Phone Number
(559) 459-6405

Facility Medical Condition Statistics

All other conditions
58
Brain disease or condition (non-traumatic)
29
Brain injury (traumatic)
43
Hip or femur fracture
32
Hip or knee replacement, amputation or other bone or joint condition
63
Nervous system disorder (excluding stroke)
Data not available for this reporting period.
Spinal cord disease or condition (non-traumatic)
24
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
0.442
SIR 95% confidence interval - upper limit
4.725
Comparative performance category
No Different than the National Benchmark
Catheter days
634
Predicted number of infections (B)
1.728
Number of infections reported (A)
3
SIR (A/B)
1.736
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
365
Denominator
365
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
7.8
Denominator
312
Average observed change score
9.0
Change in patients ability to move around
Average risk-adjusted change score
23.6
Denominator
312
Average observed change score
26.4
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
50
Denominator
312
Facility rate
16.0
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
90
Denominator
312
Facility rate
28.8
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
1
Denominator
365
Facility rate
0.3
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.013
SIR 95% confidence interval - upper limit
1.280
Comparative performance category
No Different than the National Benchmark
Patient days
10,000
Predicted number of infections (B)
3.853
Number of infections reported (A)
1
SIR (A/B)
0.260
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
114
Number of health care workers
132
Rate of flu vaccination
86.4
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
23
Number of eligible stays
356
Unadjusted potentially preventable readmission rate
6.46
Risk-standardized potentially preventable readmission rate (RSRR)
8.40
Lower limit of the 95% confidence interval on the RSRR
6.69
Upper limit of the 95% confidence interval on the RSRR
10.51
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
27
Number of eligible stays
403
Unadjusted potentially preventable readmission rate
6.70
Risk-standardized potentially preventable readmission rate (RSRR)
5.84
Lower limit of the 95% confidence interval on the RSRR
4.34
Upper limit of the 95% confidence interval on the RSRR
7.63
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)
220
Number of eligible stays
315
Observed discharge to community rate
69.84
Risk-standardized discharge to community rate
72.34
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
67.58
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
76.91
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
336
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
360
Denominator
365
Facility rate
98.6
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
1
Denominator
365
Facility observed rate
0.3
Facility risk-adjusted rate
0.2
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
54
Number of health care workers
66
Rate of COVID-19 vaccination
81.8