About the Facility
- CMS Certification Number (CCN)
- 323026
- Ownership Type
- Government
- CMS Region
- Dallas
- Certification Date
- Address
72 Gail Harris Avenue
- Phone Number
- (575) 347-3400
Facility Medical Condition Statistics
- All other conditions
- Data not available for this reporting period.
- Brain disease or condition (non-traumatic)
- -
- 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
- 19
- Nervous system disorder (excluding stroke)
- Data not available for this reporting period.
- Spinal cord disease or condition (non-traumatic)
- -
- Spinal cord injury (traumatic)
- -
- Stroke
- Data not available for this reporting period.
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
- 7
- Predicted number of infections (B)
- 0.014
- 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
- 45
- Denominator
- 47
- Facility rate
- 95.7
- Change in patients ability to care for themselves
- Average risk-adjusted change score
- 10.3
- Denominator
- 40
- Average observed change score
- 11.7
- Change in patients ability to move around
- Average risk-adjusted change score
- 29.0
- Denominator
- 40
- Average observed change score
- 37.0
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 24
- Denominator
- 40
- Facility rate
- 60.0
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 19
- Denominator
- 40
- Facility rate
- 47.5
- Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
- Numerator
- 0
- Denominator
- 47
- 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
- Not Available
- Comparative performance category
- Not Available
- Patient days
- 356
- Predicted number of infections (B)
- 0.147
- Number of infections reported (A)
- 0
- SIR (A/B)
- Not Available
- Percentage of healthcare personnel who got a flu shot for the current season
- Number of health care workers vaccinated
- 66
- Number of health care workers
- 75
- Rate of flu vaccination
- 88.0
- Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
- Number of potentially preventable readmissions following discharge
- 0
- Number of eligible stays
- 54
- Unadjusted potentially preventable readmission rate
- 0.00
- Risk-standardized potentially preventable readmission rate (RSRR)
- 8.16
- Lower limit of the 95% confidence interval on the RSRR
- 6.03
- Upper limit of the 95% confidence interval on the RSRR
- 10.86
- Comparative performance category
- No Different than the National Rate
- Rate of potentially preventable hospital readmissions during the IRF stay
- Number of potentially preventable readmissions
- 1
- Number of eligible stays
- 57
- Unadjusted potentially preventable readmission rate
- 1.75
- Risk-standardized potentially preventable readmission rate (RSRR)
- 4.65
- Lower limit of the 95% confidence interval on the RSRR
- 2.82
- Upper limit of the 95% confidence interval on the RSRR
- 7.84
- 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)
- 37
- Number of eligible stays
- 48
- Observed discharge to community rate
- 77.08
- Risk-standardized discharge to community rate
- 68.25
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 60.92
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 74.17
- Comparative performance category
- No Different than the National Rate
- Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
- MSPB score
- 0.96
- Number of eligible episodes
- 61
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 46
- Denominator
- 47
- Facility rate
- 97.9
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 0
- Denominator
- 47
- 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
- Not Available
- Number of health care workers
- Not Available
- Rate of COVID-19 vaccination
- Not Available