About the Facility
- CMS Certification Number (CCN)
- 25T034
- Ownership Type
- Non-profit
- CMS Region
- Atlanta
- Certification Date
- Address
1100 Belk Blvd.
- Phone Number
- (662) 636-4152
Facility Medical Condition Statistics
- All other conditions
- 35
- Brain disease or condition (non-traumatic)
- 17
- Brain injury (traumatic)
- -
- Hip or femur fracture
- 45
- Hip or knee replacement, amputation or other bone or joint condition
- 22
- Nervous system disorder (excluding stroke)
- Data not available for this reporting period.
- Spinal cord disease or condition (non-traumatic)
- Data not available for this reporting period.
- Spinal cord injury (traumatic)
- -
- Stroke
- 27
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
- 40
- Predicted number of infections (B)
- 0.108
- 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
- 155
- Denominator
- 155
- Facility rate
- 100.0
- Change in patients ability to care for themselves
- Average risk-adjusted change score
- 10.8
- Denominator
- 147
- Average observed change score
- 10.6
- Change in patients ability to move around
- Average risk-adjusted change score
- 25.9
- Denominator
- 147
- Average observed change score
- 25.4
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 72
- Denominator
- 147
- Facility rate
- 49.0
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 60
- Denominator
- 147
- Facility rate
- 40.8
- Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
- Numerator
- 0
- Denominator
- 155
- 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
- Not Available
- Comparative performance category
- Not Available
- Patient days
- 2,064
- Predicted number of infections (B)
- 0.650
- Number of infections reported (A)
- 0
- SIR (A/B)
- Not Available
- Percentage of healthcare personnel who got a flu shot for the current season
- Number of health care workers vaccinated
- 22
- Number of health care workers
- 26
- Rate of flu vaccination
- 84.6
- Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
- Number of potentially preventable readmissions following discharge
- 16
- Number of eligible stays
- 261
- Unadjusted potentially preventable readmission rate
- 6.13
- Risk-standardized potentially preventable readmission rate (RSRR)
- 8.40
- Lower limit of the 95% confidence interval on the RSRR
- 6.64
- Upper limit of the 95% confidence interval on the RSRR
- 10.76
- 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
- 278
- Unadjusted potentially preventable readmission rate
- 3.96
- Risk-standardized potentially preventable readmission rate (RSRR)
- 5.42
- Lower limit of the 95% confidence interval on the RSRR
- 3.86
- Upper limit of the 95% confidence interval on the RSRR
- 7.47
- 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)
- 178
- Number of eligible stays
- 224
- Observed discharge to community rate
- 79.46
- Risk-standardized discharge to community rate
- 69.17
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 65.30
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 72.87
- Comparative performance category
- No Different than the National Rate
- Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
- MSPB score
- 0.78
- Number of eligible episodes
- 252
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 153
- Denominator
- 155
- Facility rate
- 98.7
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 0
- Denominator
- 155
- Facility observed rate
- 0.0
- Facility risk-adjusted rate
- 0.0
- Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
- Number of health care workers vaccinated
- 16
- Number of health care workers
- 17
- Rate of COVID-19 vaccination
- 94.1