Queen of the Valley Hospital


About the Facility

CMS Certification Number (CCN)
05T382
Ownership Type
For Profit
CMS Region
San Francisco
Certification Date
Address
1115 S. Sunset Avenue
Phone Number
(626) 962-4011

Facility Medical Condition Statistics

All other conditions
37
Brain disease or condition (non-traumatic)
16
Brain injury (traumatic)
Data not available for this reporting period.
Hip or femur fracture
13
Hip or knee replacement, amputation or other bone or joint condition
20
Nervous system disorder (excluding stroke)
Data not available for this reporting period.
Spinal cord disease or condition (non-traumatic)
Data not available for this reporting period.
Spinal cord injury (traumatic)
Data not available for this reporting period.
Stroke
53

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
147
Predicted number of infections (B)
0.401
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
147
Denominator
147
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
11.2
Denominator
136
Average observed change score
11.9
Change in patients ability to move around
Average risk-adjusted change score
27.2
Denominator
136
Average observed change score
27.4
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
61
Denominator
136
Facility rate
44.9
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
62
Denominator
136
Facility rate
45.6
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
147
Facility rate
0.0
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
Not Available
SIR 95% confidence interval - upper limit
2.449
Comparative performance category
No Different than the National Benchmark
Patient days
3,434
Predicted number of infections (B)
1.223
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
2,266
Number of health care workers
2,436
Rate of flu vaccination
93.0
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
15
Number of eligible stays
184
Unadjusted potentially preventable readmission rate
8.15
Risk-standardized potentially preventable readmission rate (RSRR)
8.89
Lower limit of the 95% confidence interval on the RSRR
6.86
Upper limit of the 95% confidence interval on the RSRR
11.47
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
8
Number of eligible stays
206
Unadjusted potentially preventable readmission rate
3.88
Risk-standardized potentially preventable readmission rate (RSRR)
4.87
Lower limit of the 95% confidence interval on the RSRR
3.34
Upper limit of the 95% confidence interval on the RSRR
7.38
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)
110
Number of eligible stays
168
Observed discharge to community rate
65.48
Risk-standardized discharge to community rate
66.76
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
60.78
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
72.55
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
1.21
Number of eligible episodes
178
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
147
Denominator
147
Facility rate
100.0
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
3
Denominator
147
Facility observed rate
2.0
Facility risk-adjusted rate
1.8
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
2,044
Number of health care workers
2,124
Rate of COVID-19 vaccination
96.2