About the Facility
- CMS Certification Number (CCN)
- 18T080
- Ownership Type
- Non-profit
- CMS Region
- Atlanta
- Certification Date
- Address
1 Trillium Way
- Phone Number
- (606) 523-8790
Facility Medical Condition Statistics
- All other conditions
- 90
- Brain disease or condition (non-traumatic)
- -
- Brain injury (traumatic)
- Data not available for this reporting period.
- Hip or femur fracture
- 41
- Hip or knee replacement, amputation or other bone or joint condition
- 20
- Nervous system disorder (excluding stroke)
- Data not available for this reporting period.
- Spinal cord disease or condition (non-traumatic)
- 11
- Spinal cord injury (traumatic)
- Data not available for this reporting period.
- Stroke
- 62
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
- 359
- Predicted number of infections (B)
- 0.738
- Number of infections reported (A)
- 2
- SIR (A/B)
- Not Available
- Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
- Numerator
- 236
- Denominator
- 236
- Facility rate
- 100.0
- Change in patients ability to care for themselves
- Average risk-adjusted change score
- 7.9
- Denominator
- 200
- Average observed change score
- 9.8
- Change in patients ability to move around
- Average risk-adjusted change score
- 14.7
- Denominator
- 200
- Average observed change score
- 16.7
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 36
- Denominator
- 200
- Facility rate
- 18.0
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 19
- Denominator
- 200
- Facility rate
- 9.5
- Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
- Numerator
- 0
- Denominator
- 236
- 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
- 1.267
- Comparative performance category
- No Different than the National Benchmark
- Patient days
- 4,846
- Predicted number of infections (B)
- 2.365
- 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
- 26
- Number of health care workers
- 34
- Rate of flu vaccination
- 76.5
- Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
- Number of potentially preventable readmissions following discharge
- 27
- Number of eligible stays
- 265
- Unadjusted potentially preventable readmission rate
- 10.19
- Risk-standardized potentially preventable readmission rate (RSRR)
- 8.81
- Lower limit of the 95% confidence interval on the RSRR
- 7.06
- Upper limit of the 95% confidence interval on the RSRR
- 10.93
- Comparative performance category
- No Different than the National Rate
- Rate of potentially preventable hospital readmissions during the IRF stay
- Number of potentially preventable readmissions
- 20
- Number of eligible stays
- 297
- Unadjusted potentially preventable readmission rate
- 6.73
- Risk-standardized potentially preventable readmission rate (RSRR)
- 5.59
- Lower limit of the 95% confidence interval on the RSRR
- 4.23
- Upper limit of the 95% confidence interval on the RSRR
- 7.59
- 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)
- 146
- Number of eligible stays
- 247
- Observed discharge to community rate
- 59.11
- Risk-standardized discharge to community rate
- 62.48
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 56.75
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 67.87
- 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
- 245
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 215
- Denominator
- 236
- Facility rate
- 91.1
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 7
- Denominator
- 236
- Facility observed rate
- 3.0
- Facility risk-adjusted rate
- 3.0
- Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
- Number of health care workers vaccinated
- 399
- Number of health care workers
- 417
- Rate of COVID-19 vaccination
- 95.7