About the Facility
- CMS Certification Number (CCN)
- 19T039
- Ownership Type
- Non-profit
- CMS Region
- Dallas
- Certification Date
- Address
1101 Medical Center Boulevard
- Phone Number
- (502) 596-6346
Facility Medical Condition Statistics
- All other conditions
- 59
- Brain disease or condition (non-traumatic)
- 16
- Brain injury (traumatic)
- 12
- Hip or femur fracture
- 18
- Hip or knee replacement, amputation or other bone or joint condition
- 26
- Nervous system disorder (excluding stroke)
- Data not available for this reporting period.
- Spinal cord disease or condition (non-traumatic)
- 29
- Spinal cord injury (traumatic)
- Data not available for this reporting period.
- 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
- 106
- Predicted number of infections (B)
- 0.289
- 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
- 239
- Denominator
- 239
- Facility rate
- 100.0
- Change in patients ability to care for themselves
- Average risk-adjusted change score
- 12.8
- Denominator
- 209
- Average observed change score
- 13.1
- Change in patients ability to move around
- Average risk-adjusted change score
- 27.9
- Denominator
- 209
- Average observed change score
- 27.1
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 136
- Denominator
- 209
- Facility rate
- 65.1
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 105
- Denominator
- 209
- Facility rate
- 50.2
- Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
- Numerator
- 1
- Denominator
- 239
- Facility rate
- 0.4
- Clostridium difficile Infection (CDI)
- Standardized infection ratio (SIR) 95% confidence interval - lower limit
- 0.022
- SIR 95% confidence interval - upper limit
- 2.187
- Comparative performance category
- No Different than the National Benchmark
- Patient days
- 5,854
- Predicted number of infections (B)
- 2.256
- Number of infections reported (A)
- 1
- SIR (A/B)
- 0.443
- Percentage of healthcare personnel who got a flu shot for the current season
- Number of health care workers vaccinated
- 40
- Number of health care workers
- 46
- Rate of flu vaccination
- 87.0
- Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
- Number of potentially preventable readmissions following discharge
- 17
- Number of eligible stays
- 161
- Unadjusted potentially preventable readmission rate
- 10.56
- Risk-standardized potentially preventable readmission rate (RSRR)
- 9.21
- Lower limit of the 95% confidence interval on the RSRR
- 7.22
- Upper limit of the 95% confidence interval on the RSRR
- 11.76
- Comparative performance category
- No Different than the National Rate
- Rate of potentially preventable hospital readmissions during the IRF stay
- Number of potentially preventable readmissions
- 8
- Number of eligible stays
- 184
- Unadjusted potentially preventable readmission rate
- 4.35
- Risk-standardized potentially preventable readmission rate (RSRR)
- 4.71
- Lower limit of the 95% confidence interval on the RSRR
- 3.27
- Upper limit of the 95% confidence interval on the RSRR
- 7.17
- 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)
- 94
- Number of eligible stays
- 141
- Observed discharge to community rate
- 66.67
- Risk-standardized discharge to community rate
- 68.36
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 61.72
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 74.77
- Comparative performance category
- No Different than the National Rate
- Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
- MSPB score
- 0.99
- Number of eligible episodes
- 152
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 231
- Denominator
- 239
- Facility rate
- 96.7
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 0
- Denominator
- 237
- Facility observed rate
- 0.0
- Facility risk-adjusted rate
- 0.0
- Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
- Number of health care workers vaccinated
- 47
- Number of health care workers
- 47
- Rate of COVID-19 vaccination
- 100.0