About the Facility
- CMS Certification Number (CCN)
- 11T043
- Ownership Type
- Non-profit
- CMS Region
- Atlanta
- Certification Date
- Address
11705 Mercy Blvd.
- Phone Number
- (615) 500-7913
Facility Medical Condition Statistics
- All other conditions
- 128
- Brain disease or condition (non-traumatic)
- 37
- Brain injury (traumatic)
- Data not available for this reporting period.
- Hip or femur fracture
- 40
- Hip or knee replacement, amputation or other bone or joint condition
- 62
- Nervous system disorder (excluding stroke)
- Data not available for this reporting period.
- Spinal cord disease or condition (non-traumatic)
- 30
- Spinal cord injury (traumatic)
- Data not available for this reporting period.
- Stroke
- 34
Facility Quality of Patient Care Measures
- Catheter-associated urinary tract infections (CAUTI)
- Standardized infection ratio (SIR) 95% confidence interval - lower limit
- 0.041
- SIR 95% confidence interval - upper limit
- 4.000
- Comparative performance category
- No Different than the National Benchmark
- Catheter days
- 596
- Predicted number of infections (B)
- 1.233
- Number of infections reported (A)
- 1
- SIR (A/B)
- 0.811
- Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
- Numerator
- 342
- Denominator
- 342
- Facility rate
- 100.0
- Change in patients ability to care for themselves
- Average risk-adjusted change score
- 13.1
- Denominator
- 314
- Average observed change score
- 15.4
- Change in patients ability to move around
- Average risk-adjusted change score
- 33.6
- Denominator
- 314
- Average observed change score
- 36.3
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 201
- Denominator
- 314
- Facility rate
- 64.0
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 216
- Denominator
- 314
- Facility rate
- 68.8
- Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
- Numerator
- 0
- Denominator
- 342
- 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
- 0.981
- Comparative performance category
- Better than the National Benchmark
- Patient days
- 5,344
- Predicted number of infections (B)
- 3.053
- 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
- 340
- Number of health care workers
- 512
- Rate of flu vaccination
- 66.4
- Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
- Number of potentially preventable readmissions following discharge
- 38
- Number of eligible stays
- 517
- Unadjusted potentially preventable readmission rate
- 7.35
- Risk-standardized potentially preventable readmission rate (RSRR)
- 8.14
- Lower limit of the 95% confidence interval on the RSRR
- 6.64
- Upper limit of the 95% confidence interval on the RSRR
- 10.00
- Comparative performance category
- No Different than the National Rate
- Rate of potentially preventable hospital readmissions during the IRF stay
- Number of potentially preventable readmissions
- 12
- Number of eligible stays
- 544
- Unadjusted potentially preventable readmission rate
- 2.21
- Risk-standardized potentially preventable readmission rate (RSRR)
- 3.45
- Lower limit of the 95% confidence interval on the RSRR
- 2.36
- Upper limit of the 95% confidence interval on the RSRR
- 4.66
- Comparative performance category
- Better than the National Rate
- Rate of successful return to home or community from an IRF
- Observed number of discharges to community (DTC)
- 285
- Number of eligible stays
- 413
- Observed discharge to community rate
- 69.01
- Risk-standardized discharge to community rate
- 68.13
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 64.40
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 71.79
- Comparative performance category
- No Different than the National Rate
- Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
- MSPB score
- 0.98
- Number of eligible episodes
- 488
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 341
- Denominator
- 342
- Facility rate
- 99.7
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 14
- Denominator
- 340
- Facility observed rate
- 4.1
- Facility risk-adjusted rate
- 5.2
- Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
- Number of health care workers vaccinated
- 938
- Number of health care workers
- 973
- Rate of COVID-19 vaccination
- 96.4