About the Facility
- CMS Certification Number (CCN)
- 45T068
- Ownership Type
- Non-profit
- CMS Region
- Dallas
- Certification Date
- Address
6411 Fannin
- Phone Number
- (713) 704-2225
Facility Medical Condition Statistics
- All other conditions
- 45
- Brain disease or condition (non-traumatic)
- Data not available for this reporting period.
- Brain injury (traumatic)
- 23
- Hip or femur fracture
- Data not available for this reporting period.
- Hip or knee replacement, amputation or other bone or joint condition
- 11
- 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)
- -
- Stroke
- 67
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
- 152
- Predicted number of infections (B)
- 0.414
- 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
- 7.5
- Denominator
- 131
- Average observed change score
- 7.9
- Change in patients ability to move around
- Average risk-adjusted change score
- 19.2
- Denominator
- 131
- Average observed change score
- 20.2
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 26
- Denominator
- 131
- Facility rate
- 19.8
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 29
- Denominator
- 131
- Facility rate
- 22.1
- 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
- Not Available
- SIR 95% confidence interval - upper limit
- 1.737
- Comparative performance category
- No Different than the National Benchmark
- Patient days
- 4,475
- Predicted number of infections (B)
- 1.724
- 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
- 94
- Number of health care workers
- 94
- 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
- 63
- Unadjusted potentially preventable readmission rate
- 12.70
- Risk-standardized potentially preventable readmission rate (RSRR)
- 8.68
- Lower limit of the 95% confidence interval on the RSRR
- 6.79
- Upper limit of the 95% confidence interval on the RSRR
- 11.11
- Comparative performance category
- No Different than the National Rate
- Rate of potentially preventable hospital readmissions during the IRF stay
- Number of potentially preventable readmissions
- 9
- Number of eligible stays
- 81
- Unadjusted potentially preventable readmission rate
- 11.11
- Risk-standardized potentially preventable readmission rate (RSRR)
- 5.51
- Lower limit of the 95% confidence interval on the RSRR
- 3.97
- Upper limit of the 95% confidence interval on the RSRR
- 7.32
- 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)
- 38
- Number of eligible stays
- 63
- Observed discharge to community rate
- 60.32
- Risk-standardized discharge to community rate
- 66.65
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 57.80
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 75.56
- Comparative performance category
- No Different than the National Rate
- Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
- MSPB score
- 1.01
- Number of eligible episodes
- 61
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 172
- Denominator
- 174
- Facility rate
- 98.9
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 2
- Denominator
- 174
- Facility observed rate
- 1.1
- Facility risk-adjusted rate
- 1.4
- Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
- Number of health care workers vaccinated
- 68
- Number of health care workers
- 68
- Rate of COVID-19 vaccination
- 100.0