About the Facility
- CMS Certification Number (CCN)
- 37T019
- Ownership Type
- Non-profit
- CMS Region
- Dallas
- Certification Date
- Address
1801 West 3rd Street
- Phone Number
- -
Facility Medical Condition Statistics
- All other conditions
- 27
- 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
- 18
- Hip or knee replacement, amputation or other bone or joint condition
- 35
- 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
- 30
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
- 102
- Predicted number of infections (B)
- 0.187
- 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
- 117
- Denominator
- 117
- Facility rate
- 100.0
- Change in patients ability to care for themselves
- Average risk-adjusted change score
- 12.4
- Denominator
- 107
- Average observed change score
- 11.7
- Change in patients ability to move around
- Average risk-adjusted change score
- 35.0
- Denominator
- 107
- Average observed change score
- 36.9
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 69
- Denominator
- 107
- Facility rate
- 64.5
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 81
- Denominator
- 107
- Facility rate
- 75.7
- Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
- Numerator
- 0
- Denominator
- 117
- 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
- Not Available
- Comparative performance category
- Not Available
- Patient days
- 1,360
- Predicted number of infections (B)
- 0.484
- Number of infections reported (A)
- 0
- SIR (A/B)
- Not Available
- Percentage of healthcare personnel who got a flu shot for the current season
- Number of health care workers vaccinated
- 17
- Number of health care workers
- 17
- Rate of flu vaccination
- 100.0
- Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
- Number of potentially preventable readmissions following discharge
- 8
- Number of eligible stays
- 165
- Unadjusted potentially preventable readmission rate
- 4.85
- Risk-standardized potentially preventable readmission rate (RSRR)
- 8.31
- Lower limit of the 95% confidence interval on the RSRR
- 6.46
- Upper limit of the 95% confidence interval on the RSRR
- 10.85
- Comparative performance category
- No Different than the National Rate
- Rate of potentially preventable hospital readmissions during the IRF stay
- Number of potentially preventable readmissions
- 3
- Number of eligible stays
- 172
- Unadjusted potentially preventable readmission rate
- 1.74
- Risk-standardized potentially preventable readmission rate (RSRR)
- 4.37
- Lower limit of the 95% confidence interval on the RSRR
- 2.61
- 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)
- 102
- Number of eligible stays
- 137
- Observed discharge to community rate
- 74.45
- Risk-standardized discharge to community rate
- 66.41
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 61.08
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 71.36
- Comparative performance category
- No Different than the National Rate
- Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
- MSPB score
- 1.00
- Number of eligible episodes
- 194
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 117
- Denominator
- 117
- Facility rate
- 100.0
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 0
- Denominator
- 116
- Facility observed rate
- 0.0
- Facility risk-adjusted rate
- 0.0
- Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
- Number of health care workers vaccinated
- 16
- Number of health care workers
- 19
- Rate of COVID-19 vaccination
- 84.2