About the Facility
- CMS Certification Number (CCN)
- 453029
- Ownership Type
- For Profit
- CMS Region
- Dallas
- Certification Date
- Address
19002 Mckay Drive
- Phone Number
- (281) 319-9509
Facility Medical Condition Statistics
- All other conditions
- 179
- Brain disease or condition (non-traumatic)
- 87
- Brain injury (traumatic)
- 21
- Hip or femur fracture
- 73
- Hip or knee replacement, amputation or other bone or joint condition
- 170
- Nervous system disorder (excluding stroke)
- 178
- Spinal cord disease or condition (non-traumatic)
- 25
- Spinal cord injury (traumatic)
- Data not available for this reporting period.
- Stroke
- 165
Facility Quality of Patient Care Measures
- Catheter-associated urinary tract infections (CAUTI)
- Standardized infection ratio (SIR) 95% confidence interval - lower limit
- 0.036
- SIR 95% confidence interval - upper limit
- 3.530
- Comparative performance category
- No Different than the National Benchmark
- Catheter days
- 1,292
- Predicted number of infections (B)
- 1.397
- Number of infections reported (A)
- 1
- SIR (A/B)
- 0.716
- Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
- Numerator
- 879
- Denominator
- 879
- Facility rate
- 100.0
- Change in patients ability to care for themselves
- Average risk-adjusted change score
- 14.0
- Denominator
- 758
- Average observed change score
- 13.5
- Change in patients ability to move around
- Average risk-adjusted change score
- 35.4
- Denominator
- 758
- Average observed change score
- 31.9
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 532
- Denominator
- 758
- Facility rate
- 70.2
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 515
- Denominator
- 758
- Facility rate
- 67.9
- Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
- Numerator
- 1
- Denominator
- 879
- Facility rate
- 0.1
- Clostridium difficile Infection (CDI)
- Standardized infection ratio (SIR) 95% confidence interval - lower limit
- 0.164
- SIR 95% confidence interval - upper limit
- 1.759
- Comparative performance category
- No Different than the National Benchmark
- Patient days
- 14,541
- Predicted number of infections (B)
- 4.642
- Number of infections reported (A)
- 3
- SIR (A/B)
- 0.646
- Percentage of healthcare personnel who got a flu shot for the current season
- Number of health care workers vaccinated
- 287
- Number of health care workers
- 366
- Rate of flu vaccination
- 78.4
- Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
- Number of potentially preventable readmissions following discharge
- 101
- Number of eligible stays
- 645
- Unadjusted potentially preventable readmission rate
- 15.66
- Risk-standardized potentially preventable readmission rate (RSRR)
- 10.41
- Lower limit of the 95% confidence interval on the RSRR
- 8.98
- Upper limit of the 95% confidence interval on the RSRR
- 12.12
- Comparative performance category
- Worse than the National Rate
- Rate of potentially preventable hospital readmissions during the IRF stay
- Number of potentially preventable readmissions
- 53
- Number of eligible stays
- 739
- Unadjusted potentially preventable readmission rate
- 7.17
- Risk-standardized potentially preventable readmission rate (RSRR)
- 5.32
- Lower limit of the 95% confidence interval on the RSRR
- 4.29
- Upper limit of the 95% confidence interval on the RSRR
- 6.53
- 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)
- 303
- Number of eligible stays
- 513
- Observed discharge to community rate
- 59.06
- Risk-standardized discharge to community rate
- 66.88
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 62.78
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 71.09
- Comparative performance category
- No Different than the National Rate
- Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
- MSPB score
- 1.07
- Number of eligible episodes
- 923
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 854
- Denominator
- 879
- Facility rate
- 97.2
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 6
- Denominator
- 878
- Facility observed rate
- 0.7
- Facility risk-adjusted rate
- 0.5
- Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
- Number of health care workers vaccinated
- 217
- Number of health care workers
- 265
- Rate of COVID-19 vaccination
- 81.9