Pam Health Rehabilitation Hospital of Westminster


About the Facility

CMS Certification Number (CCN)
063037
Ownership Type
For Profit
CMS Region
Denver
Certification Date
Address
6500 W 104th Ave
Phone Number
(720) 653-3440

Facility Medical Condition Statistics

All other conditions
62
Brain disease or condition (non-traumatic)
86
Brain injury (traumatic)
34
Hip or femur fracture
45
Hip or knee replacement, amputation or other bone or joint condition
68
Nervous system disorder (excluding stroke)
252
Spinal cord disease or condition (non-traumatic)
28
Spinal cord injury (traumatic)
13
Stroke
104

Facility Quality of Patient Care Measures

Catheter-associated urinary tract infections (CAUTI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.021
SIR 95% confidence interval - upper limit
2.052
Comparative performance category
No Different than the National Benchmark
Catheter days
1,669
Predicted number of infections (B)
2.404
Number of infections reported (A)
1
SIR (A/B)
0.416
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
675
Denominator
675
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
10.0
Denominator
571
Average observed change score
12.8
Change in patients ability to move around
Average risk-adjusted change score
25.4
Denominator
571
Average observed change score
27.6
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
230
Denominator
571
Facility rate
40.3
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
217
Denominator
571
Facility rate
38.0
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
1
Denominator
675
Facility rate
0.1
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
Not Available
SIR 95% confidence interval - upper limit
0.760
Comparative performance category
Better than the National Benchmark
Patient days
9,256
Predicted number of infections (B)
3.943
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
119
Number of health care workers
194
Rate of flu vaccination
61.3
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
13
Number of eligible stays
185
Unadjusted potentially preventable readmission rate
7.03
Risk-standardized potentially preventable readmission rate (RSRR)
8.17
Lower limit of the 95% confidence interval on the RSRR
6.44
Upper limit of the 95% confidence interval on the RSRR
10.22
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
12
Number of eligible stays
208
Unadjusted potentially preventable readmission rate
5.77
Risk-standardized potentially preventable readmission rate (RSRR)
5.05
Lower limit of the 95% confidence interval on the RSRR
3.57
Upper limit of the 95% confidence interval on the RSRR
6.94
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)
114
Number of eligible stays
190
Observed discharge to community rate
60.00
Risk-standardized discharge to community rate
63.01
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
57.13
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
68.64
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
1.05
Number of eligible episodes
222
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
671
Denominator
675
Facility rate
99.4
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
6
Denominator
673
Facility observed rate
0.9
Facility risk-adjusted rate
0.7
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
142
Number of health care workers
158
Rate of COVID-19 vaccination
89.9