About the Facility
- CMS Certification Number (CCN)
- 193067
- Ownership Type
- Physician
- CMS Region
- Dallas
- Certification Date
- Address
1 Hospital Drive, Suite 101
- Phone Number
- (337) 821-5353
Facility Medical Condition Statistics
- All other conditions
- 55
- 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
- 29
- Hip or knee replacement, amputation or other bone or joint condition
- 45
- Nervous system disorder (excluding stroke)
- 51
- Spinal cord disease or condition (non-traumatic)
- 29
- Spinal cord injury (traumatic)
- Data not available for this reporting period.
- Stroke
- 36
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
- 633
- Predicted number of infections (B)
- 0.980
- 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
- 245
- Denominator
- 245
- Facility rate
- 100.0
- Change in patients ability to care for themselves
- Average risk-adjusted change score
- 9.9
- Denominator
- 206
- Average observed change score
- 11.5
- Change in patients ability to move around
- Average risk-adjusted change score
- 29.4
- Denominator
- 206
- Average observed change score
- 31.7
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 74
- Denominator
- 206
- Facility rate
- 35.9
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 105
- Denominator
- 206
- Facility rate
- 51.0
- Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
- Numerator
- 1
- Denominator
- 245
- Facility rate
- 0.4
- Clostridium difficile Infection (CDI)
- Standardized infection ratio (SIR) 95% confidence interval - lower limit
- 0.217
- SIR 95% confidence interval - upper limit
- 4.277
- Comparative performance category
- No Different than the National Benchmark
- Patient days
- 3,745
- Predicted number of infections (B)
- 1.545
- Number of infections reported (A)
- 2
- SIR (A/B)
- 1.295
- Percentage of healthcare personnel who got a flu shot for the current season
- Number of health care workers vaccinated
- 36
- Number of health care workers
- 58
- Rate of flu vaccination
- 62.1
- Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
- Number of potentially preventable readmissions following discharge
- 21
- Number of eligible stays
- 270
- Unadjusted potentially preventable readmission rate
- 7.78
- Risk-standardized potentially preventable readmission rate (RSRR)
- 8.80
- Lower limit of the 95% confidence interval on the RSRR
- 7.01
- Upper limit of the 95% confidence interval on the RSRR
- 11.09
- Comparative performance category
- No Different than the National Rate
- Rate of potentially preventable hospital readmissions during the IRF stay
- Number of potentially preventable readmissions
- 12
- Number of eligible stays
- 293
- Unadjusted potentially preventable readmission rate
- 4.10
- Risk-standardized potentially preventable readmission rate (RSRR)
- 4.92
- Lower limit of the 95% confidence interval on the RSRR
- 3.58
- Upper limit of the 95% confidence interval on the RSRR
- 7.08
- 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)
- 138
- Number of eligible stays
- 207
- Observed discharge to community rate
- 66.67
- Risk-standardized discharge to community rate
- 65.33
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 60.44
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 70.21
- Comparative performance category
- No Different than the National Rate
- Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
- MSPB score
- 1.02
- Number of eligible episodes
- 301
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 240
- Denominator
- 245
- Facility rate
- 98.0
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 5
- Denominator
- 244
- Facility observed rate
- 2.0
- Facility risk-adjusted rate
- 1.7
- Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
- Number of health care workers vaccinated
- 37
- Number of health care workers
- 49
- Rate of COVID-19 vaccination
- 75.5