About the Facility
- CMS Certification Number (CCN)
- 10T157
- Ownership Type
- Non-profit
- CMS Region
- Atlanta
- Certification Date
- Address
1324 Lakeland Hills Blvd
- Phone Number
- (863) 687-1100
Facility Medical Condition Statistics
- All other conditions
- 185
- Brain disease or condition (non-traumatic)
- 37
- Brain injury (traumatic)
- 20
- Hip or femur fracture
- 112
- Hip or knee replacement, amputation or other bone or joint condition
- 91
- Nervous system disorder (excluding stroke)
- 18
- Spinal cord disease or condition (non-traumatic)
- 23
- Spinal cord injury (traumatic)
- Data not available for this reporting period.
- Stroke
- 122
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
- 1.902
- Comparative performance category
- No Different than the National Benchmark
- Catheter days
- 820
- Predicted number of infections (B)
- 1.575
- Number of infections reported (A)
- 0
- SIR (A/B)
- 0.000
- Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
- Numerator
- 602
- Denominator
- 602
- Facility rate
- 100.0
- Change in patients ability to care for themselves
- Average risk-adjusted change score
- 14.4
- Denominator
- 525
- Average observed change score
- 13.8
- Change in patients ability to move around
- Average risk-adjusted change score
- 35.0
- Denominator
- 528
- Average observed change score
- 34.0
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 409
- Denominator
- 528
- Facility rate
- 77.5
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 378
- Denominator
- 528
- Facility rate
- 71.6
- Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
- Numerator
- 0
- Denominator
- 602
- Facility rate
- 0.0
- Clostridium difficile Infection (CDI)
- Standardized infection ratio (SIR) 95% confidence interval - lower limit
- 0.008
- SIR 95% confidence interval - upper limit
- 0.823
- Comparative performance category
- Better than the National Benchmark
- Patient days
- 9,939
- Predicted number of infections (B)
- 5.991
- Number of infections reported (A)
- 1
- SIR (A/B)
- 0.167
- Percentage of healthcare personnel who got a flu shot for the current season
- Number of health care workers vaccinated
- 116
- Number of health care workers
- 126
- Rate of flu vaccination
- 92.1
- Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
- Number of potentially preventable readmissions following discharge
- 43
- Number of eligible stays
- 518
- Unadjusted potentially preventable readmission rate
- 8.30
- Risk-standardized potentially preventable readmission rate (RSRR)
- 9.15
- Lower limit of the 95% confidence interval on the RSRR
- 7.49
- Upper limit of the 95% confidence interval on the RSRR
- 11.00
- Comparative performance category
- No Different than the National Rate
- Rate of potentially preventable hospital readmissions during the IRF stay
- Number of potentially preventable readmissions
- 19
- Number of eligible stays
- 572
- Unadjusted potentially preventable readmission rate
- 3.32
- Risk-standardized potentially preventable readmission rate (RSRR)
- 4.39
- Lower limit of the 95% confidence interval on the RSRR
- 3.30
- Upper limit of the 95% confidence interval on the RSRR
- 5.85
- 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)
- 316
- Number of eligible stays
- 461
- Observed discharge to community rate
- 68.55
- Risk-standardized discharge to community rate
- 66.34
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 62.52
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 69.97
- Comparative performance category
- No Different than the National Rate
- Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
- MSPB score
- 0.94
- Number of eligible episodes
- 480
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 553
- Denominator
- 602
- Facility rate
- 91.9
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 3
- Denominator
- 600
- Facility observed rate
- 0.5
- Facility risk-adjusted rate
- 0.4
- Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
- Number of health care workers vaccinated
- 93
- Number of health care workers
- 117
- Rate of COVID-19 vaccination
- 79.5