About the Facility
- CMS Certification Number (CCN)
- 32T002
- Ownership Type
- Non-profit
- CMS Region
- Dallas
- Certification Date
- Address
455 St Michaels Drive
- Phone Number
- (505) 913-5392
Facility Medical Condition Statistics
- All other conditions
- 42
- Brain disease or condition (non-traumatic)
- Data not available for this reporting period.
- Brain injury (traumatic)
- 12
- Hip or femur fracture
- 86
- Hip or knee replacement, amputation or other bone or joint condition
- 55
- Nervous system disorder (excluding stroke)
- Data not available for this reporting period.
- Spinal cord disease or condition (non-traumatic)
- Data not available for this reporting period.
- Spinal cord injury (traumatic)
- -
- Stroke
- 70
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
- 335
- Predicted number of infections (B)
- 0.637
- Number of infections reported (A)
- 1
- SIR (A/B)
- Not Available
- Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
- Numerator
- 275
- Denominator
- 275
- Facility rate
- 100.0
- Change in patients ability to care for themselves
- Average risk-adjusted change score
- 9.7
- Denominator
- 249
- Average observed change score
- 11.4
- Change in patients ability to move around
- Average risk-adjusted change score
- 20.5
- Denominator
- 249
- Average observed change score
- 23.3
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 91
- Denominator
- 249
- Facility rate
- 36.5
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 73
- Denominator
- 249
- Facility rate
- 29.3
- Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
- Numerator
- 3
- Denominator
- 275
- Facility rate
- 1.1
- Clostridium difficile Infection (CDI)
- Standardized infection ratio (SIR) 95% confidence interval - lower limit
- 0.030
- SIR 95% confidence interval - upper limit
- 2.963
- Comparative performance category
- No Different than the National Benchmark
- Patient days
- 4,189
- Predicted number of infections (B)
- 1.664
- Number of infections reported (A)
- 1
- SIR (A/B)
- 0.601
- Percentage of healthcare personnel who got a flu shot for the current season
- Number of health care workers vaccinated
- 52
- Number of health care workers
- 70
- Rate of flu vaccination
- 74.3
- Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
- Number of potentially preventable readmissions following discharge
- 11
- Number of eligible stays
- 320
- Unadjusted potentially preventable readmission rate
- 3.44
- Risk-standardized potentially preventable readmission rate (RSRR)
- 7.79
- Lower limit of the 95% confidence interval on the RSRR
- 5.95
- Upper limit of the 95% confidence interval on the RSRR
- 10.07
- Comparative performance category
- No Different than the National Rate
- Rate of potentially preventable hospital readmissions during the IRF stay
- Number of potentially preventable readmissions
- 13
- Number of eligible stays
- 342
- Unadjusted potentially preventable readmission rate
- 3.80
- Risk-standardized potentially preventable readmission rate (RSRR)
- 5.37
- Lower limit of the 95% confidence interval on the RSRR
- 3.51
- Upper limit of the 95% confidence interval on the RSRR
- 6.67
- 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)
- 205
- Number of eligible stays
- 286
- Observed discharge to community rate
- 71.68
- Risk-standardized discharge to community rate
- 65.84
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 61.66
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 69.71
- Comparative performance category
- No Different than the National Rate
- Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
- MSPB score
- 0.88
- Number of eligible episodes
- 323
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 97
- Denominator
- 275
- Facility rate
- 35.3
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 2
- Denominator
- 274
- Facility observed rate
- 0.7
- Facility risk-adjusted rate
- 1.0
- Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
- Number of health care workers vaccinated
- 77
- Number of health care workers
- 80
- Rate of COVID-19 vaccination
- 96.3