About the Facility
- CMS Certification Number (CCN)
- 34T155
- Ownership Type
- Government
- CMS Region
- Atlanta
- Certification Date
- Address
3643 N Roxboro Road
Box 52
- Phone Number
- (919) 470-7226
Facility Medical Condition Statistics
- All other conditions
- 67
- Brain disease or condition (non-traumatic)
- 40
- Brain injury (traumatic)
- Data not available for this reporting period.
- Hip or femur fracture
- 28
- Hip or knee replacement, amputation or other bone or joint condition
- 44
- Nervous system disorder (excluding stroke)
- 13
- Spinal cord disease or condition (non-traumatic)
- 47
- Spinal cord injury (traumatic)
- Data not available for this reporting period.
- Stroke
- 82
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
- 354
- Predicted number of infections (B)
- 0.771
- Number of infections reported (A)
- 1
- SIR (A/B)
- Not Available
- Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
- Numerator
- 327
- Denominator
- 327
- Facility rate
- 100.0
- Change in patients ability to care for themselves
- Average risk-adjusted change score
- 7.7
- Denominator
- 287
- Average observed change score
- 9.8
- Change in patients ability to move around
- Average risk-adjusted change score
- 23.6
- Denominator
- 287
- Average observed change score
- 26.9
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 70
- Denominator
- 287
- Facility rate
- 24.4
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 105
- Denominator
- 287
- Facility rate
- 36.6
- Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
- Numerator
- 0
- Denominator
- 327
- Facility rate
- 0.0
- Clostridium difficile Infection (CDI)
- Standardized infection ratio (SIR) 95% confidence interval - lower limit
- 0.012
- SIR 95% confidence interval - upper limit
- 1.179
- Comparative performance category
- No Different than the National Benchmark
- Patient days
- 8,546
- Predicted number of infections (B)
- 4.182
- Number of infections reported (A)
- 1
- SIR (A/B)
- 0.239
- Percentage of healthcare personnel who got a flu shot for the current season
- Number of health care workers vaccinated
- 3,792
- Number of health care workers
- 4,023
- Rate of flu vaccination
- 94.3
- 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
- 325
- Unadjusted potentially preventable readmission rate
- 8.31
- Risk-standardized potentially preventable readmission rate (RSRR)
- 8.76
- Lower limit of the 95% confidence interval on the RSRR
- 6.94
- Upper limit of the 95% confidence interval on the RSRR
- 10.86
- Comparative performance category
- No Different than the National Rate
- Rate of potentially preventable hospital readmissions during the IRF stay
- Number of potentially preventable readmissions
- 16
- Number of eligible stays
- 354
- Unadjusted potentially preventable readmission rate
- 4.52
- Risk-standardized potentially preventable readmission rate (RSRR)
- 4.76
- Lower limit of the 95% confidence interval on the RSRR
- 3.57
- Upper limit of the 95% confidence interval on the RSRR
- 6.28
- 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)
- 195
- Number of eligible stays
- 280
- Observed discharge to community rate
- 69.64
- Risk-standardized discharge to community rate
- 69.85
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 65.05
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 74.45
- 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
- 293
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 315
- Denominator
- 327
- Facility rate
- 96.3
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 2
- Denominator
- 327
- Facility observed rate
- 0.6
- Facility risk-adjusted rate
- 0.7
- Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
- Number of health care workers vaccinated
- 2,970
- Number of health care workers
- 3,162
- Rate of COVID-19 vaccination
- 93.9