About the Facility
- CMS Certification Number (CCN)
- 32T005
- Ownership Type
- Non-profit
- CMS Region
- Dallas
- Certification Date
- Address
801 West Maple Street
- Phone Number
- (505) 609-2000
Facility Medical Condition Statistics
- All other conditions
- 41
- Brain disease or condition (non-traumatic)
- 13
- Brain injury (traumatic)
- 12
- Hip or femur fracture
- 56
- Hip or knee replacement, amputation or other bone or joint condition
- 34
- 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)
- Data not available for this reporting period.
- Stroke
- 52
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
- 191
- Predicted number of infections (B)
- 0.276
- Number of infections reported (A)
- 2
- SIR (A/B)
- Not Available
- Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
- Numerator
- 217
- Denominator
- 217
- Facility rate
- 100.0
- Change in patients ability to care for themselves
- Average risk-adjusted change score
- 11.9
- Denominator
- 208
- Average observed change score
- 13.2
- Change in patients ability to move around
- Average risk-adjusted change score
- 33.8
- Denominator
- 208
- Average observed change score
- 37.0
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 127
- Denominator
- 208
- Facility rate
- 61.1
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 147
- Denominator
- 208
- Facility rate
- 70.7
- Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
- Numerator
- 0
- Denominator
- 217
- 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
- 2.076
- Comparative performance category
- No Different than the National Benchmark
- Patient days
- 3,515
- Predicted number of infections (B)
- 1.443
- Number of infections reported (A)
- 0
- SIR (A/B)
- 0.000
- Percentage of healthcare personnel who got a flu shot for the current season
- Number of health care workers vaccinated
- 13
- Number of health care workers
- 17
- Rate of flu vaccination
- 76.5
- Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
- Number of potentially preventable readmissions following discharge
- 15
- Number of eligible stays
- 216
- Unadjusted potentially preventable readmission rate
- 6.94
- Risk-standardized potentially preventable readmission rate (RSRR)
- 9.17
- Lower limit of the 95% confidence interval on the RSRR
- 7.06
- Upper limit of the 95% confidence interval on the RSRR
- 11.60
- 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
- 228
- Unadjusted potentially preventable readmission rate
- 3.51
- Risk-standardized potentially preventable readmission rate (RSRR)
- 4.97
- Lower limit of the 95% confidence interval on the RSRR
- 3.16
- Upper limit of the 95% confidence interval on the RSRR
- 7.36
- 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)
- 145
- Number of eligible stays
- 193
- Observed discharge to community rate
- 75.13
- Risk-standardized discharge to community rate
- 68.46
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 63.43
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 72.78
- Comparative performance category
- No Different than the National Rate
- Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
- MSPB score
- 0.89
- Number of eligible episodes
- 205
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 217
- Denominator
- 217
- Facility rate
- 100.0
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 2
- Denominator
- 217
- Facility observed rate
- 0.9
- Facility risk-adjusted rate
- 1.1
- Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
- Number of health care workers vaccinated
- 21
- Number of health care workers
- 21
- Rate of COVID-19 vaccination
- 100.0