About the Facility
- CMS Certification Number (CCN)
- 11T038
- Ownership Type
- Non-profit
- CMS Region
- Atlanta
- Certification Date
- Address
Gordon Ave. @ Mimosa Drive
P.o. Box 1018
- Phone Number
- (229) 228-8063
Facility Medical Condition Statistics
- All other conditions
- Data not available for this reporting period.
- Brain disease or condition (non-traumatic)
- Data not available for this reporting period.
- Brain injury (traumatic)
- Data not available for this reporting period.
- Hip or femur fracture
- 25
- Hip or knee replacement, amputation or other bone or joint condition
- 14
- Nervous system disorder (excluding stroke)
- 73
- 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
- 25
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
- 181
- Predicted number of infections (B)
- 0.374
- 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
- 156
- Denominator
- 156
- Facility rate
- 100.0
- Change in patients ability to care for themselves
- Average risk-adjusted change score
- 13.0
- Denominator
- 142
- Average observed change score
- 14.4
- Change in patients ability to move around
- Average risk-adjusted change score
- 30.2
- Denominator
- 142
- Average observed change score
- 34.0
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 98
- Denominator
- 142
- Facility rate
- 69.0
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 84
- Denominator
- 142
- Facility rate
- 59.2
- Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
- Numerator
- 0
- Denominator
- 156
- 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
- 2.687
- Comparative performance category
- No Different than the National Benchmark
- Patient days
- 2,501
- Predicted number of infections (B)
- 1.115
- 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
- 72
- Number of health care workers
- 78
- Rate of flu vaccination
- 92.3
- Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
- Number of potentially preventable readmissions following discharge
- 10
- Number of eligible stays
- 195
- Unadjusted potentially preventable readmission rate
- 5.13
- Risk-standardized potentially preventable readmission rate (RSRR)
- 7.86
- Lower limit of the 95% confidence interval on the RSRR
- 6.12
- Upper limit of the 95% confidence interval on the RSRR
- 10.06
- Comparative performance category
- No Different than the National Rate
- Rate of potentially preventable hospital readmissions during the IRF stay
- Number of potentially preventable readmissions
- 6
- Number of eligible stays
- 211
- Unadjusted potentially preventable readmission rate
- 2.84
- Risk-standardized potentially preventable readmission rate (RSRR)
- 4.51
- Lower limit of the 95% confidence interval on the RSRR
- 3.19
- Upper limit of the 95% confidence interval on the RSRR
- 6.82
- 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)
- 126
- Number of eligible stays
- 174
- Observed discharge to community rate
- 72.41
- Risk-standardized discharge to community rate
- 69.21
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 63.50
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 73.97
- Comparative performance category
- No Different than the National Rate
- Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
- MSPB score
- 0.86
- Number of eligible episodes
- 203
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 47
- Denominator
- 156
- Facility rate
- 30.1
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 2
- Denominator
- 156
- Facility observed rate
- 1.3
- Facility risk-adjusted rate
- 1.7
- Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
- Number of health care workers vaccinated
- 33
- Number of health care workers
- 38
- Rate of COVID-19 vaccination
- 86.8