ENCOMPASS HEALTH LAKESHORE REHABILITATION HOSPITAL

CMS Certification Number

013025

Ownership Type

For profit

Catheter-associated urinary tract infections (CAUTI) - Standardized infection ratio (SIR) 95% confidence interval - lower limit

0.387

-

Other Measure

2.936

-

Catheter-associated urinary tract infections (CAUTI) - Comparative performance category

No Different than the National Benchmark

-

Catheter-associated urinary tract infections (CAUTI) - Catheter days

3,041

-

Catheter-associated urinary tract infections (CAUTI) - Predicted number of infections (B)

3.286

-

Catheter-associated urinary tract infections (CAUTI) - Number of infections reported (A)

4

-

Catheter-associated urinary tract infections (CAUTI)

1.217

-

Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan - Denominator

1,789

-

Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan - Numerator

1,789

-

Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan

100.0

-

Percentage of IRF patients who experience one or more falls with major injury during their IRF stay - Denominator

1,789

-

Percentage of IRF patients who experience one or more falls with major injury during their IRF stay - Numerator

1

-

Percentage of IRF patients who experience one or more falls with major injury during their IRF stay

0.1

-

Change in patients' ability to care for themselves

14.7

-

Change in patients' ability to care for themselves - Denominator

1,532

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Change in patients' ability to care for themselves - Average observed change score

14.5

-

Change in patients' ability to move around

36.4

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Change in patients' ability to move around - Denominator

1,532

-

Change in patients' ability to move around - Average observed change score

35.7

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Percentage of patients who are at or above an expected ability to care for themselves at discharge - Denominator

1,532

-

Percentage of patients who are at or above an expected ability to care for themselves at discharge - Numerator

1,236

-

Percentage of patients who are at or above an expected ability to care for themselves at discharge

80.7

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Percentage of patients who are at or above an expected ability to care for themselves at discharge - Denominator

1,532

-

Percentage of patients who are at or above an expected ability to care for themselves at discharge - Numerator

1,190

-

Percentage of patients who are at or above an expected ability to move around at discharge

77.7

-

Clostridium difficile Infection (CDI) - Standardized infection ratio (SIR) 95% confidence interval - lower limit

0.273

-

Clostridium difficile Infection (CDI) - SIR 95% confidence interval - upper limit

1.234

-

Clostridium difficile Infection (CDI) - Comparative performance category

No Different than the National Benchmark

-

Clostridium difficile Infection (CDI) - Patient days

31,892

-

Clostridium difficile Infection (CDI) - Predicted number of infections (B)

11.217

-

Clostridium difficile Infection (CDI) - Number of infections reported (A)

7

-

Clostridium difficile Infection (CDI)

0.624

-

Percentage of healthcare personnel who got a flu shot for the current season - Number of health care workers

567

-

Percentage of healthcare personnel who got a flu shot for the current season - Number of health care workers vaccinated

458

-

Percentage of healthcare personnel who got a flu shot for the current season

80.8

-

Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF - Comparative performance category

No Different than the National Rate

-

Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF - Unadjusted potentially preventable readmission rate

10.71

-

Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF - Number of potentially preventable readmissions following discharge

189

-

Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF

9.40

-

Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF - Lower limit of the 95% confidence interval on the RSRR

8.26

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Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF - Upper limit of the 95% confidence interval on the RSRR

10.62

-

Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF - Number of eligible stays

1,764

-

Rate of potentially preventable hospital readmissions during the IRF stay - Comparative performance category

No Different than the National Rate

-

Rate of potentially preventable hospital readmissions during the IRF stay - Unadjusted potentially preventable readmission rate

5.84

-

Rate of potentially preventable hospital readmissions during the IRF stay - Number of potentially preventable readmissions

116

-

Rate of potentially preventable hospital readmissions during the IRF stay

5.34

-

Rate of potentially preventable hospital readmissions during the IRF stay - Lower limit of the 95% confidence interval on the RSRR

4.42

-

Rate of potentially preventable hospital readmissions during the IRF stay - Upper limit of the 95% confidence interval on the RSRR

6.39

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Rate of potentially preventable hospital readmissions during the IRF stay - Number of eligible stays

1,988

-

Rate of successful return to home or community from an IRF - Comparative performance category

Better than the National Rate

-

Rate of successful return to home or community from an IRF - Observed number of discharges to community (DTC)

1,050

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Rate of successful return to home or community from an IRF - Observed discharge to community rate

66.62

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Rate of successful return to home or community from an IRF

69.57

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Rate of successful return to home or community from an IRF - Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate

67.13

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Rate of successful return to home or community from an IRF - Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate

71.94

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Rate of successful return to home or community from an IRF - Number of eligible stays

1,576

-

Medicare Spending Per Beneficiary (MSPB) for patients in IRFs - Number of eligible episodes

1,839

-

Medicare Spending Per Beneficiary (MSPB) for patients in IRFs

0.99

-

Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified - Denominator

1,789

-

Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified - Numerator

1,784

-

Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified

99.7

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Other Measure

0.6

-

Other Measure

1,786

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Other Measure

11

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Percentage of patients with pressure ulcers/pressure injuries that are new or worsened

0.6

-

Other Measure

481

-

Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series - Number of health care workers vaccinated

389

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Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series

80.9

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