Lovelace Unm Rehabilitation Hospital


About the Facility

CMS Certification Number (CCN)
323028
Ownership Type
For Profit
CMS Region
Dallas
Certification Date
Address
505 Elm Street Ne
Phone Number
(505) 727-4781

Facility Medical Condition Statistics

All other conditions
223
Brain disease or condition (non-traumatic)
57
Brain injury (traumatic)
32
Hip or femur fracture
125
Hip or knee replacement, amputation or other bone or joint condition
156
Nervous system disorder (excluding stroke)
52
Spinal cord disease or condition (non-traumatic)
58
Spinal cord injury (traumatic)
12
Stroke
205

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
1.720
Comparative performance category
No Different than the National Benchmark
Catheter days
1,125
Predicted number of infections (B)
1.742
Number of infections reported (A)
0
SIR (A/B)
0.000
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
901
Denominator
902
Facility rate
99.9
Change in patients ability to care for themselves
Average risk-adjusted change score
12.0
Denominator
777
Average observed change score
13.5
Change in patients ability to move around
Average risk-adjusted change score
29.9
Denominator
777
Average observed change score
32.7
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
451
Denominator
777
Facility rate
58.0
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
430
Denominator
777
Facility rate
55.3
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
5
Denominator
901
Facility rate
0.6
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.046
SIR 95% confidence interval - upper limit
0.899
Comparative performance category
Better than the National Benchmark
Patient days
17,823
Predicted number of infections (B)
7.353
Number of infections reported (A)
2
SIR (A/B)
0.272
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
405
Number of health care workers
426
Rate of flu vaccination
95.1
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
38
Number of eligible stays
545
Unadjusted potentially preventable readmission rate
6.97
Risk-standardized potentially preventable readmission rate (RSRR)
8.55
Lower limit of the 95% confidence interval on the RSRR
6.90
Upper limit of the 95% confidence interval on the RSRR
10.49
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
30
Number of eligible stays
608
Unadjusted potentially preventable readmission rate
4.93
Risk-standardized potentially preventable readmission rate (RSRR)
5.27
Lower limit of the 95% confidence interval on the RSRR
3.78
Upper limit of the 95% confidence interval on the RSRR
6.79
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)
321
Number of eligible stays
475
Observed discharge to community rate
67.58
Risk-standardized discharge to community rate
66.51
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
62.41
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
70.16
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
0.92
Number of eligible episodes
531
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
871
Denominator
902
Facility rate
96.6
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
8
Denominator
901
Facility observed rate
0.9
Facility risk-adjusted rate
0.8
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
283
Number of health care workers
298
Rate of COVID-19 vaccination
95.0