About the Facility
- CMS Certification Number (CCN)
- 32T063
- Ownership Type
- Non-profit
- CMS Region
- Dallas
- Certification Date
- Address
2430 West Pierce Street
- Phone Number
- (505) 887-4396
Facility Medical Condition Statistics
- All other conditions
- 53
- Brain disease or condition (non-traumatic)
- Data not available for this reporting period.
- Brain injury (traumatic)
- Data not available for this reporting period.
- Hip or femur fracture
- 46
- Hip or knee replacement, amputation or other bone or joint condition
- 23
- Nervous system disorder (excluding stroke)
- 18
- Spinal cord disease or condition (non-traumatic)
- Data not available for this reporting period.
- Spinal cord injury (traumatic)
- -
- Stroke
- 18
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
- 166
- Predicted number of infections (B)
- 0.240
- 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
- 174
- Denominator
- 174
- Facility rate
- 100.0
- Change in patients ability to care for themselves
- Average risk-adjusted change score
- 14.3
- Denominator
- 160
- Average observed change score
- 15.3
- Change in patients ability to move around
- Average risk-adjusted change score
- 36.3
- Denominator
- 160
- Average observed change score
- 39.1
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 130
- Denominator
- 160
- Facility rate
- 81.3
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 125
- Denominator
- 160
- Facility rate
- 78.1
- Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
- Numerator
- 0
- Denominator
- 174
- Facility rate
- 0.0
- Clostridium difficile Infection (CDI)
- Standardized infection ratio (SIR) 95% confidence interval - lower limit
- 0.293
- SIR 95% confidence interval - upper limit
- 5.780
- Comparative performance category
- No Different than the National Benchmark
- Patient days
- 2,628
- Predicted number of infections (B)
- 1.143
- Number of infections reported (A)
- 2
- SIR (A/B)
- 1.749
- Percentage of healthcare personnel who got a flu shot for the current season
- Number of health care workers vaccinated
- 164
- Number of health care workers
- 500
- Rate of flu vaccination
- 32.8
- Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
- Number of potentially preventable readmissions following discharge
- 9
- Number of eligible stays
- 125
- Unadjusted potentially preventable readmission rate
- 7.20
- Risk-standardized potentially preventable readmission rate (RSRR)
- 8.75
- Lower limit of the 95% confidence interval on the RSRR
- 6.84
- Upper limit of the 95% confidence interval on the RSRR
- 11.36
- Comparative performance category
- No Different than the National Rate
- Rate of potentially preventable hospital readmissions during the IRF stay
- Number of potentially preventable readmissions
- 6
- Number of eligible stays
- 134
- Unadjusted potentially preventable readmission rate
- 4.48
- Risk-standardized potentially preventable readmission rate (RSRR)
- 5.06
- Lower limit of the 95% confidence interval on the RSRR
- 3.37
- Upper limit of the 95% confidence interval on the RSRR
- 7.06
- 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)
- 79
- Number of eligible stays
- 103
- Observed discharge to community rate
- 76.70
- Risk-standardized discharge to community rate
- 70.11
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 63.87
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 75.88
- Comparative performance category
- No Different than the National Rate
- Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
- MSPB score
- 0.99
- Number of eligible episodes
- 169
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 168
- Denominator
- 174
- Facility rate
- 96.6
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 1
- Denominator
- 172
- Facility observed rate
- 0.6
- Facility risk-adjusted rate
- 0.6
- Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
- Number of health care workers vaccinated
- 371
- Number of health care workers
- 388
- Rate of COVID-19 vaccination
- 95.6