About the Facility
- CMS Certification Number (CCN)
- 04T071
- Ownership Type
- Non-profit
- CMS Region
- Dallas
- Certification Date
- Address
1600 West 40th Ave.
- Phone Number
- (502) 596-6346
Facility Medical Condition Statistics
- All other conditions
- 85
- Brain disease or condition (non-traumatic)
- 47
- Brain injury (traumatic)
- Data not available for this reporting period.
- Hip or femur fracture
- 76
- Hip or knee replacement, amputation or other bone or joint condition
- 103
- Nervous system disorder (excluding stroke)
- 172
- Spinal cord disease or condition (non-traumatic)
- 16
- Spinal cord injury (traumatic)
- -
- Stroke
- 77
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
- 649
- Predicted number of infections (B)
- 0.936
- 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
- 577
- Denominator
- 579
- Facility rate
- 99.7
- Change in patients ability to care for themselves
- Average risk-adjusted change score
- 12.3
- Denominator
- 516
- Average observed change score
- 12.5
- Change in patients ability to move around
- Average risk-adjusted change score
- 31.4
- Denominator
- 516
- Average observed change score
- 30.6
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 321
- Denominator
- 516
- Facility rate
- 62.2
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 296
- Denominator
- 516
- Facility rate
- 57.4
- Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
- Numerator
- 1
- Denominator
- 579
- Facility rate
- 0.2
- Clostridium difficile Infection (CDI)
- Standardized infection ratio (SIR) 95% confidence interval - lower limit
- 0.090
- SIR 95% confidence interval - upper limit
- 1.767
- Comparative performance category
- No Different than the National Benchmark
- Patient days
- 7,377
- Predicted number of infections (B)
- 3.740
- Number of infections reported (A)
- 2
- SIR (A/B)
- 0.535
- Percentage of healthcare personnel who got a flu shot for the current season
- Number of health care workers vaccinated
- 44
- Number of health care workers
- 44
- Rate of flu vaccination
- 100.0
- Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
- Number of potentially preventable readmissions following discharge
- 44
- Number of eligible stays
- 534
- Unadjusted potentially preventable readmission rate
- 8.24
- Risk-standardized potentially preventable readmission rate (RSRR)
- 8.48
- Lower limit of the 95% confidence interval on the RSRR
- 7.13
- Upper limit of the 95% confidence interval on the RSRR
- 10.35
- Comparative performance category
- No Different than the National Rate
- Rate of potentially preventable hospital readmissions during the IRF stay
- Number of potentially preventable readmissions
- 29
- Number of eligible stays
- 602
- Unadjusted potentially preventable readmission rate
- 4.82
- Risk-standardized potentially preventable readmission rate (RSRR)
- 5.03
- Lower limit of the 95% confidence interval on the RSRR
- 4.11
- Upper limit of the 95% confidence interval on the RSRR
- 6.56
- 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)
- 295
- Number of eligible stays
- 481
- Observed discharge to community rate
- 61.33
- Risk-standardized discharge to community rate
- 62.82
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 58.98
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 66.83
- Comparative performance category
- Worse than the National Rate
- Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
- MSPB score
- 1.04
- Number of eligible episodes
- 547
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 573
- Denominator
- 579
- Facility rate
- 99.0
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 12
- Denominator
- 577
- Facility observed rate
- 2.1
- Facility risk-adjusted rate
- 1.7
- Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
- Number of health care workers vaccinated
- 20
- Number of health care workers
- 24
- Rate of COVID-19 vaccination
- 83.3