About the Facility
- CMS Certification Number (CCN)
- 04T039
- Ownership Type
- Non-profit
- CMS Region
- Dallas
- Certification Date
- Address
900 West Kings Highway
- Phone Number
- (502) 596-6346
Facility Medical Condition Statistics
- All other conditions
- 43
- Brain disease or condition (non-traumatic)
- 27
- Brain injury (traumatic)
- Data not available for this reporting period.
- Hip or femur fracture
- 20
- Hip or knee replacement, amputation or other bone or joint condition
- 34
- Nervous system disorder (excluding stroke)
- 57
- Spinal cord disease or condition (non-traumatic)
- -
- 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
- 483
- Predicted number of infections (B)
- 0.698
- 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
- 210
- Denominator
- 210
- Facility rate
- 100.0
- Change in patients ability to care for themselves
- Average risk-adjusted change score
- 16.6
- Denominator
- 186
- Average observed change score
- 18.6
- Change in patients ability to move around
- Average risk-adjusted change score
- 37.0
- Denominator
- 186
- Average observed change score
- 38.9
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 158
- Denominator
- 186
- Facility rate
- 84.9
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 144
- Denominator
- 186
- Facility rate
- 77.4
- Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
- Numerator
- 0
- Denominator
- 210
- 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
- 2.414
- Comparative performance category
- No Different than the National Benchmark
- Patient days
- 2,564
- Predicted number of infections (B)
- 1.241
- 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
- Not Available
- Number of health care workers
- Not Available
- Rate of flu vaccination
- Not Available
- Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
- Number of potentially preventable readmissions following discharge
- 22
- Number of eligible stays
- 259
- Unadjusted potentially preventable readmission rate
- 8.49
- Risk-standardized potentially preventable readmission rate (RSRR)
- 8.54
- Lower limit of the 95% confidence interval on the RSRR
- 6.81
- Upper limit of the 95% confidence interval on the RSRR
- 10.71
- 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
- 287
- Unadjusted potentially preventable readmission rate
- 3.83
- Risk-standardized potentially preventable readmission rate (RSRR)
- 4.52
- Lower limit of the 95% confidence interval on the RSRR
- 3.11
- Upper limit of the 95% confidence interval on the RSRR
- 6.52
- 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)
- 143
- Number of eligible stays
- 231
- Observed discharge to community rate
- 61.90
- Risk-standardized discharge to community rate
- 63.24
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 57.51
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 68.19
- Comparative performance category
- No Different than the National Rate
- Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
- MSPB score
- 1.04
- Number of eligible episodes
- 304
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 197
- Denominator
- 210
- Facility rate
- 93.8
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 4
- Denominator
- 210
- Facility observed rate
- 1.9
- Facility risk-adjusted rate
- 1.8
- Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
- Number of health care workers vaccinated
- 24
- Number of health care workers
- 24
- Rate of COVID-19 vaccination
- 100.0