Alhambra Hospital Medical Center


About the Facility

CMS Certification Number (CCN)
05T281
Ownership Type
For Profit
CMS Region
San Francisco
Certification Date
Address
100 S. Raymond Avenue
Phone Number
(626) 458-4767

Facility Medical Condition Statistics

All other conditions
22
Brain disease or condition (non-traumatic)
54
Brain injury (traumatic)
Data not available for this reporting period.
Hip or femur fracture
33
Hip or knee replacement, amputation or other bone or joint condition
Data not available for this reporting period.
Nervous system disorder (excluding stroke)
Data not available for this reporting period.
Spinal cord disease or condition (non-traumatic)
34
Spinal cord injury (traumatic)
Data not available for this reporting period.
Stroke
34

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
348
Predicted number of infections (B)
0.719
Number of infections reported (A)
2
SIR (A/B)
Not Available
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
198
Denominator
198
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
15.7
Denominator
174
Average observed change score
15.6
Change in patients ability to move around
Average risk-adjusted change score
34.6
Denominator
174
Average observed change score
29.5
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
127
Denominator
174
Facility rate
73.0
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
110
Denominator
174
Facility rate
63.2
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
1
Denominator
198
Facility rate
0.5
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
Not Available
SIR 95% confidence interval - upper limit
1.769
Comparative performance category
No Different than the National Benchmark
Patient days
3,612
Predicted number of infections (B)
1.694
Number of infections reported (A)
0
SIR (A/B)
0.000
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
74
Number of health care workers
80
Rate of flu vaccination
92.5
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
19
Number of eligible stays
269
Unadjusted potentially preventable readmission rate
7.06
Risk-standardized potentially preventable readmission rate (RSRR)
8.24
Lower limit of the 95% confidence interval on the RSRR
6.52
Upper limit of the 95% confidence interval on the RSRR
10.28
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
13
Number of eligible stays
284
Unadjusted potentially preventable readmission rate
4.58
Risk-standardized potentially preventable readmission rate (RSRR)
4.60
Lower limit of the 95% confidence interval on the RSRR
3.32
Upper limit of the 95% confidence interval on the RSRR
6.93
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)
178
Number of eligible stays
244
Observed discharge to community rate
72.95
Risk-standardized discharge to community rate
76.17
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
70.78
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
80.87
Comparative performance category
Better than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
1.14
Number of eligible episodes
272
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
198
Denominator
198
Facility rate
100.0
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
6
Denominator
198
Facility observed rate
3.0
Facility risk-adjusted rate
1.8
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
65
Number of health care workers
65
Rate of COVID-19 vaccination
100.0