About the Facility
- CMS Certification Number (CCN)
- 43T027
- Ownership Type
- Non-profit
- CMS Region
- Denver
- Certification Date
- Address
1305 W 18th Street
- Phone Number
- (605) 328-6758
Facility Medical Condition Statistics
- All other conditions
- 25
- Brain disease or condition (non-traumatic)
- 16
- Brain injury (traumatic)
- 25
- Hip or femur fracture
- Data not available for this reporting period.
- 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)
- Data not available for this reporting period.
- Stroke
- 117
Facility Quality of Patient Care Measures
- Catheter-associated urinary tract infections (CAUTI)
- Standardized infection ratio (SIR) 95% confidence interval - lower limit
- 0.042
- SIR 95% confidence interval - upper limit
- 4.113
- Comparative performance category
- No Different than the National Benchmark
- Catheter days
- 582
- Predicted number of infections (B)
- 1.199
- Number of infections reported (A)
- 1
- SIR (A/B)
- 0.834
- Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
- Numerator
- 222
- Denominator
- 222
- Facility rate
- 100.0
- Change in patients ability to care for themselves
- Average risk-adjusted change score
- 12.5
- Denominator
- 170
- Average observed change score
- 12.2
- Change in patients ability to move around
- Average risk-adjusted change score
- 32.2
- Denominator
- 170
- Average observed change score
- 32.9
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 103
- Denominator
- 170
- Facility rate
- 60.6
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 112
- Denominator
- 170
- Facility rate
- 65.9
- Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
- Numerator
- 0
- Denominator
- 222
- 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
- 1.177
- Comparative performance category
- No Different than the National Benchmark
- Patient days
- 6,628
- Predicted number of infections (B)
- 2.546
- 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
- 131
- Number of health care workers
- 139
- Rate of flu vaccination
- 94.2
- Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
- Number of potentially preventable readmissions following discharge
- 19
- Number of eligible stays
- 248
- Unadjusted potentially preventable readmission rate
- 7.66
- Risk-standardized potentially preventable readmission rate (RSRR)
- 9.05
- Lower limit of the 95% confidence interval on the RSRR
- 6.98
- Upper limit of the 95% confidence interval on the RSRR
- 11.61
- 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
- 277
- Unadjusted potentially preventable readmission rate
- 4.33
- Risk-standardized potentially preventable readmission rate (RSRR)
- 4.94
- Lower limit of the 95% confidence interval on the RSRR
- 3.62
- Upper limit of the 95% confidence interval on the RSRR
- 7.17
- 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)
- 137
- Number of eligible stays
- 235
- Observed discharge to community rate
- 58.30
- Risk-standardized discharge to community rate
- 58.96
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 53.04
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 64.33
- Comparative performance category
- Worse than the National Rate
- Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
- MSPB score
- 0.99
- Number of eligible episodes
- 226
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 204
- Denominator
- 222
- Facility rate
- 91.9
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 3
- Denominator
- 222
- Facility observed rate
- 1.4
- Facility risk-adjusted rate
- 1.5
- Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
- Number of health care workers vaccinated
- 37
- Number of health care workers
- 41
- Rate of COVID-19 vaccination
- 90.2