About the Facility
- CMS Certification Number (CCN)
- 04T078
- Ownership Type
- For Profit
- CMS Region
- Dallas
- Certification Date
- Address
1910 Malvern Ave.
- Phone Number
- (502) 596-6346
Facility Medical Condition Statistics
- All other conditions
- 52
- Brain disease or condition (non-traumatic)
- 61
- Brain injury (traumatic)
- Data not available for this reporting period.
- Hip or femur fracture
- 48
- Hip or knee replacement, amputation or other bone or joint condition
- 81
- Nervous system disorder (excluding stroke)
- 154
- Spinal cord disease or condition (non-traumatic)
- Data not available for this reporting period.
- Spinal cord injury (traumatic)
- -
- Stroke
- 28
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
- 277
- Predicted number of infections (B)
- 0.400
- Number of infections reported (A)
- 1
- SIR (A/B)
- Not Available
- Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
- Numerator
- 433
- Denominator
- 433
- Facility rate
- 100.0
- Change in patients ability to care for themselves
- Average risk-adjusted change score
- 13.2
- Denominator
- 388
- Average observed change score
- 14.8
- Change in patients ability to move around
- Average risk-adjusted change score
- 28.3
- Denominator
- 388
- Average observed change score
- 28.0
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 272
- Denominator
- 388
- Facility rate
- 70.1
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 215
- Denominator
- 388
- Facility rate
- 55.4
- Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
- Numerator
- 1
- Denominator
- 433
- Facility rate
- 0.2
- Clostridium difficile Infection (CDI)
- Standardized infection ratio (SIR) 95% confidence interval - lower limit
- 0.224
- SIR 95% confidence interval - upper limit
- 4.423
- Comparative performance category
- No Different than the National Benchmark
- Patient days
- 4,599
- Predicted number of infections (B)
- 1.494
- Number of infections reported (A)
- 2
- SIR (A/B)
- 1.339
- Percentage of healthcare personnel who got a flu shot for the current season
- Number of health care workers vaccinated
- 16
- Number of health care workers
- 31
- Rate of flu vaccination
- 51.6
- Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
- Number of potentially preventable readmissions following discharge
- 35
- Number of eligible stays
- 411
- Unadjusted potentially preventable readmission rate
- 8.52
- Risk-standardized potentially preventable readmission rate (RSRR)
- 8.83
- Lower limit of the 95% confidence interval on the RSRR
- 7.09
- Upper limit of the 95% confidence interval on the RSRR
- 10.88
- Comparative performance category
- No Different than the National Rate
- Rate of potentially preventable hospital readmissions during the IRF stay
- Number of potentially preventable readmissions
- 19
- Number of eligible stays
- 458
- Unadjusted potentially preventable readmission rate
- 4.15
- Risk-standardized potentially preventable readmission rate (RSRR)
- 5.10
- Lower limit of the 95% confidence interval on the RSRR
- 3.65
- Upper limit of the 95% confidence interval on the RSRR
- 6.93
- 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)
- 223
- Number of eligible stays
- 355
- Observed discharge to community rate
- 62.82
- Risk-standardized discharge to community rate
- 60.36
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 56.35
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 64.27
- Comparative performance category
- Worse than the National Rate
- Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
- MSPB score
- 0.94
- Number of eligible episodes
- 429
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 433
- Denominator
- 433
- Facility rate
- 100.0
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 10
- Denominator
- 432
- Facility observed rate
- 2.3
- Facility risk-adjusted rate
- 2.5
- 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