About the Facility
- CMS Certification Number (CCN)
- 323027
- Ownership Type
- For Profit
- CMS Region
- Dallas
- Certification Date
- Address
7000 Jefferson Street Ne
- Phone Number
- (505) 344-9478
Facility Medical Condition Statistics
- All other conditions
- 181
- Brain disease or condition (non-traumatic)
- 78
- Brain injury (traumatic)
- 33
- Hip or femur fracture
- 141
- Hip or knee replacement, amputation or other bone or joint condition
- 189
- Nervous system disorder (excluding stroke)
- 183
- Spinal cord disease or condition (non-traumatic)
- 46
- Spinal cord injury (traumatic)
- Data not available for this reporting period.
- Stroke
- 191
Facility Quality of Patient Care Measures
- Catheter-associated urinary tract infections (CAUTI)
- Standardized infection ratio (SIR) 95% confidence interval - lower limit
- 0.249
- SIR 95% confidence interval - upper limit
- 2.661
- Comparative performance category
- No Different than the National Benchmark
- Catheter days
- 1,981
- Predicted number of infections (B)
- 3.068
- Number of infections reported (A)
- 3
- SIR (A/B)
- 0.978
- Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
- Numerator
- 1,007
- Denominator
- 1,008
- Facility rate
- 99.9
- Change in patients ability to care for themselves
- Average risk-adjusted change score
- 13.1
- Denominator
- 869
- Average observed change score
- 13.1
- Change in patients ability to move around
- Average risk-adjusted change score
- 31.8
- Denominator
- 869
- Average observed change score
- 31.5
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 591
- Denominator
- 869
- Facility rate
- 68.0
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 543
- Denominator
- 869
- Facility rate
- 62.5
- Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
- Numerator
- 2
- Denominator
- 1,008
- Facility rate
- 0.2
- Clostridium difficile Infection (CDI)
- Standardized infection ratio (SIR) 95% confidence interval - lower limit
- 0.005
- SIR 95% confidence interval - upper limit
- 0.534
- Comparative performance category
- Better than the National Benchmark
- Patient days
- 20,312
- Predicted number of infections (B)
- 9.237
- Number of infections reported (A)
- 1
- SIR (A/B)
- 0.108
- Percentage of healthcare personnel who got a flu shot for the current season
- Number of health care workers vaccinated
- 299
- Number of health care workers
- 340
- Rate of flu vaccination
- 87.9
- Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
- Number of potentially preventable readmissions following discharge
- 56
- Number of eligible stays
- 632
- Unadjusted potentially preventable readmission rate
- 8.86
- Risk-standardized potentially preventable readmission rate (RSRR)
- 9.70
- Lower limit of the 95% confidence interval on the RSRR
- 8.02
- Upper limit of the 95% confidence interval on the RSRR
- 11.59
- Comparative performance category
- No Different than the National Rate
- Rate of potentially preventable hospital readmissions during the IRF stay
- Number of potentially preventable readmissions
- 38
- Number of eligible stays
- 715
- Unadjusted potentially preventable readmission rate
- 5.31
- Risk-standardized potentially preventable readmission rate (RSRR)
- 5.80
- Lower limit of the 95% confidence interval on the RSRR
- 4.38
- Upper limit of the 95% confidence interval on the RSRR
- 7.15
- 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)
- 394
- Number of eligible stays
- 571
- Observed discharge to community rate
- 69.00
- Risk-standardized discharge to community rate
- 66.58
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 63.01
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 69.83
- Comparative performance category
- No Different than the National Rate
- Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
- MSPB score
- 0.90
- Number of eligible episodes
- 666
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 987
- Denominator
- 1,008
- Facility rate
- 97.9
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 7
- Denominator
- 1,003
- Facility observed rate
- 0.7
- Facility risk-adjusted rate
- 0.8
- Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
- Number of health care workers vaccinated
- 311
- Number of health care workers
- 325
- Rate of COVID-19 vaccination
- 95.7