About the Facility
- CMS Certification Number (CCN)
- 10T125
- Ownership Type
- Non-profit
- CMS Region
- Atlanta
- Certification Date
- Address
975 Baptist Way
- Phone Number
- (786) 243-8000
Facility Medical Condition Statistics
- All other conditions
- 103
- Brain disease or condition (non-traumatic)
- 26
- Brain injury (traumatic)
- 16
- Hip or femur fracture
- 56
- Hip or knee replacement, amputation or other bone or joint condition
- 81
- Nervous system disorder (excluding stroke)
- 19
- 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
- 93
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
- 447
- Predicted number of infections (B)
- 0.850
- Number of infections reported (A)
- 1
- SIR (A/B)
- Not Available
- Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
- Numerator
- 393
- Denominator
- 393
- Facility rate
- 100.0
- Change in patients ability to care for themselves
- Average risk-adjusted change score
- 9.2
- Denominator
- 344
- Average observed change score
- 11.4
- Change in patients ability to move around
- Average risk-adjusted change score
- 24.9
- Denominator
- 344
- Average observed change score
- 27.9
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 92
- Denominator
- 344
- Facility rate
- 26.7
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 124
- Denominator
- 344
- Facility rate
- 36.0
- Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
- Numerator
- 2
- Denominator
- 393
- 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
- 1.205
- Comparative performance category
- No Different than the National Benchmark
- Patient days
- 7,614
- Predicted number of infections (B)
- 2.486
- 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
- 307
- Number of health care workers
- 331
- Rate of flu vaccination
- 92.7
- Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
- Number of potentially preventable readmissions following discharge
- 37
- Number of eligible stays
- 353
- Unadjusted potentially preventable readmission rate
- 10.48
- Risk-standardized potentially preventable readmission rate (RSRR)
- 9.69
- Lower limit of the 95% confidence interval on the RSRR
- 7.77
- Upper limit of the 95% confidence interval on the RSRR
- 12.01
- Comparative performance category
- No Different than the National Rate
- Rate of potentially preventable hospital readmissions during the IRF stay
- Number of potentially preventable readmissions
- 11
- Number of eligible stays
- 381
- Unadjusted potentially preventable readmission rate
- 2.89
- Risk-standardized potentially preventable readmission rate (RSRR)
- 3.87
- Lower limit of the 95% confidence interval on the RSRR
- 2.82
- Upper limit of the 95% confidence interval on the RSRR
- 5.76
- 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)
- 208
- Number of eligible stays
- 301
- Observed discharge to community rate
- 69.10
- Risk-standardized discharge to community rate
- 71.08
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 66.57
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 75.71
- Comparative performance category
- No Different than the National Rate
- Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
- MSPB score
- 1.11
- Number of eligible episodes
- 356
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 390
- Denominator
- 393
- Facility rate
- 99.2
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 6
- Denominator
- 392
- Facility observed rate
- 1.5
- Facility risk-adjusted rate
- 1.7
- Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
- Number of health care workers vaccinated
- 122
- Number of health care workers
- 131
- Rate of COVID-19 vaccination
- 93.1