About the Facility
- CMS Certification Number (CCN)
- 45T072
- Ownership Type
- Non-profit
- CMS Region
- Dallas
- Certification Date
- Address
100 Medical Drive
- Phone Number
- (979) 285-1869
Facility Medical Condition Statistics
- All other conditions
- 37
- Brain disease or condition (non-traumatic)
- 13
- Brain injury (traumatic)
- Data not available for this reporting period.
- Hip or femur fracture
- 25
- Hip or knee replacement, amputation or other bone or joint condition
- 12
- Nervous system disorder (excluding stroke)
- 21
- 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
- 22
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
- 42
- Predicted number of infections (B)
- 0.115
- 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
- 141
- Denominator
- 141
- Facility rate
- 100.0
- Change in patients ability to care for themselves
- Average risk-adjusted change score
- 12.4
- Denominator
- 130
- Average observed change score
- 11.1
- Change in patients ability to move around
- Average risk-adjusted change score
- 36.1
- Denominator
- 130
- Average observed change score
- 38.3
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 81
- Denominator
- 130
- Facility rate
- 62.3
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 96
- Denominator
- 130
- Facility rate
- 73.8
- Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
- Numerator
- 1
- Denominator
- 141
- Facility rate
- 0.7
- 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
- 1,901
- Predicted number of infections (B)
- 0.732
- 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
- 14
- Number of health care workers
- 19
- Rate of flu vaccination
- 73.7
- Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
- Number of potentially preventable readmissions following discharge
- 15
- Number of eligible stays
- 137
- Unadjusted potentially preventable readmission rate
- 10.95
- Risk-standardized potentially preventable readmission rate (RSRR)
- 9.28
- Lower limit of the 95% confidence interval on the RSRR
- 7.18
- Upper limit of the 95% confidence interval on the RSRR
- 11.96
- Comparative performance category
- No Different than the National Rate
- Rate of potentially preventable hospital readmissions during the IRF stay
- Number of potentially preventable readmissions
- 5
- Number of eligible stays
- 150
- Unadjusted potentially preventable readmission rate
- 3.33
- Risk-standardized potentially preventable readmission rate (RSRR)
- 4.69
- Lower limit of the 95% confidence interval on the RSRR
- 3.01
- Upper limit of the 95% confidence interval on the RSRR
- 7.39
- 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
- 120
- Observed discharge to community rate
- 65.83
- Risk-standardized discharge to community rate
- 64.20
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 57.84
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 70.42
- Comparative performance category
- No Different than the National Rate
- Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
- MSPB score
- 0.95
- Number of eligible episodes
- 141
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 119
- Denominator
- 141
- Facility rate
- 84.4
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 6
- Denominator
- 140
- Facility observed rate
- 4.3
- Facility risk-adjusted rate
- 4.8
- Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
- Number of health care workers vaccinated
- 11
- Number of health care workers
- 16
- Rate of COVID-19 vaccination
- 68.8