About the Facility
- CMS Certification Number (CCN)
- 37T020
- Ownership Type
- Non-profit
- CMS Region
- Dallas
- Certification Date
- Address
430 North Monte Vista
- Phone Number
- (580) 421-1183
Facility Medical Condition Statistics
- All other conditions
- 27
- Brain disease or condition (non-traumatic)
- 11
- Brain injury (traumatic)
- Data not available for this reporting period.
- Hip or femur fracture
- 49
- Hip or knee replacement, amputation or other bone or joint condition
- 16
- 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
- 31
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
- 155
- Predicted number of infections (B)
- 0.223
- 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
- 148
- Denominator
- 148
- Facility rate
- 100.0
- Change in patients ability to care for themselves
- Average risk-adjusted change score
- 13.4
- Denominator
- 132
- Average observed change score
- 15.8
- Change in patients ability to move around
- Average risk-adjusted change score
- 33.8
- Denominator
- 132
- Average observed change score
- 38.1
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 99
- Denominator
- 132
- Facility rate
- 75.0
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 93
- Denominator
- 132
- Facility rate
- 70.5
- Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
- Numerator
- 0
- Denominator
- 148
- 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
- 2,233
- Predicted number of infections (B)
- 0.971
- 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
- 15
- Number of health care workers
- 15
- 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
- 160
- Unadjusted potentially preventable readmission rate
- 5.00
- Risk-standardized potentially preventable readmission rate (RSRR)
- 8.08
- Lower limit of the 95% confidence interval on the RSRR
- 6.33
- Upper limit of the 95% confidence interval on the RSRR
- 10.33
- 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
- 173
- Unadjusted potentially preventable readmission rate
- 3.47
- Risk-standardized potentially preventable readmission rate (RSRR)
- 4.72
- Lower limit of the 95% confidence interval on the RSRR
- 3.16
- Upper limit of the 95% confidence interval on the RSRR
- 6.94
- 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)
- 104
- Number of eligible stays
- 143
- Observed discharge to community rate
- 72.73
- Risk-standardized discharge to community rate
- 68.74
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 62.56
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 74.25
- Comparative performance category
- No Different than the National Rate
- Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
- MSPB score
- 1.03
- Number of eligible episodes
- 154
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 140
- Denominator
- 148
- Facility rate
- 94.6
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 0
- Denominator
- 147
- 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
- 13
- Number of health care workers
- 15
- Rate of COVID-19 vaccination
- 86.7