About the Facility
- CMS Certification Number (CCN)
- 43T077
- Ownership Type
- Non-profit
- CMS Region
- Denver
- Certification Date
- Address
1050 Fairmont Blvd
- Phone Number
- (605) 755-1205
Facility Medical Condition Statistics
- All other conditions
- 23
- Brain disease or condition (non-traumatic)
- Data not available for this reporting period.
- Brain injury (traumatic)
- Data not available for this reporting period.
- Hip or femur fracture
- 27
- Hip or knee replacement, amputation or other bone or joint condition
- 70
- 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
- 48
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
- 374
- Predicted number of infections (B)
- 0.773
- Number of infections reported (A)
- 3
- SIR (A/B)
- Not Available
- Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
- Numerator
- 201
- Denominator
- 201
- Facility rate
- 100.0
- Change in patients ability to care for themselves
- Average risk-adjusted change score
- 12.1
- Denominator
- 179
- Average observed change score
- 13.2
- Change in patients ability to move around
- Average risk-adjusted change score
- 30.5
- Denominator
- 179
- Average observed change score
- 33.9
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 109
- Denominator
- 179
- Facility rate
- 60.9
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 110
- Denominator
- 179
- Facility rate
- 61.5
- Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
- Numerator
- 0
- Denominator
- 201
- 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
- 1.240
- Comparative performance category
- No Different than the National Benchmark
- Patient days
- 5,142
- Predicted number of infections (B)
- 2.417
- 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
- 99
- Number of health care workers
- 105
- 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
- 17
- Number of eligible stays
- 187
- Unadjusted potentially preventable readmission rate
- 9.09
- Risk-standardized potentially preventable readmission rate (RSRR)
- 9.47
- Lower limit of the 95% confidence interval on the RSRR
- 7.27
- Upper limit of the 95% confidence interval on the RSRR
- 12.21
- Comparative performance category
- No Different than the National Rate
- Rate of potentially preventable hospital readmissions during the IRF stay
- Number of potentially preventable readmissions
- 15
- Number of eligible stays
- 208
- Unadjusted potentially preventable readmission rate
- 7.21
- Risk-standardized potentially preventable readmission rate (RSRR)
- 6.40
- Lower limit of the 95% confidence interval on the RSRR
- 4.49
- Upper limit of the 95% confidence interval on the RSRR
- 9.12
- 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)
- 121
- Number of eligible stays
- 175
- Observed discharge to community rate
- 69.14
- Risk-standardized discharge to community rate
- 66.62
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 60.94
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 71.81
- Comparative performance category
- No Different than the National Rate
- Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
- MSPB score
- 1.00
- Number of eligible episodes
- 180
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 200
- Denominator
- 201
- Facility rate
- 99.5
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 1
- Denominator
- 199
- Facility observed rate
- 0.5
- Facility risk-adjusted rate
- 0.7
- Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
- Number of health care workers vaccinated
- 39
- Number of health care workers
- 43
- Rate of COVID-19 vaccination
- 90.7