About the Facility
- CMS Certification Number (CCN)
- 45T184
- Ownership Type
- Non-profit
- CMS Region
- Dallas
- Certification Date
- Address
7737 Sw Fwy
- Phone Number
- (713) 867-3394
Facility Medical Condition Statistics
- All other conditions
- 62
- Brain disease or condition (non-traumatic)
- 63
- Brain injury (traumatic)
- 71
- Hip or femur fracture
- 126
- Hip or knee replacement, amputation or other bone or joint condition
- 94
- Nervous system disorder (excluding stroke)
- 34
- Spinal cord disease or condition (non-traumatic)
- 86
- Spinal cord injury (traumatic)
- Data not available for this reporting period.
- Stroke
- 332
Facility Quality of Patient Care Measures
- Catheter-associated urinary tract infections (CAUTI)
- Standardized infection ratio (SIR) 95% confidence interval - lower limit
- 0.595
- SIR 95% confidence interval - upper limit
- 4.519
- Comparative performance category
- No Different than the National Benchmark
- Catheter days
- 783
- Predicted number of infections (B)
- 2.135
- Number of infections reported (A)
- 4
- SIR (A/B)
- 1.874
- Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
- Numerator
- 872
- Denominator
- 872
- Facility rate
- 100.0
- Change in patients ability to care for themselves
- Average risk-adjusted change score
- 10.9
- Denominator
- 760
- Average observed change score
- 10.8
- Change in patients ability to move around
- Average risk-adjusted change score
- 28.2
- Denominator
- 760
- Average observed change score
- 27.6
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 353
- Denominator
- 760
- Facility rate
- 46.4
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 376
- Denominator
- 760
- Facility rate
- 49.5
- Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
- Numerator
- 0
- Denominator
- 872
- Facility rate
- 0.0
- Clostridium difficile Infection (CDI)
- Standardized infection ratio (SIR) 95% confidence interval - lower limit
- 0.121
- SIR 95% confidence interval - upper limit
- 1.298
- Comparative performance category
- No Different than the National Benchmark
- Patient days
- 17,446
- Predicted number of infections (B)
- 6.289
- Number of infections reported (A)
- 3
- SIR (A/B)
- 0.477
- Percentage of healthcare personnel who got a flu shot for the current season
- Number of health care workers vaccinated
- 432
- Number of health care workers
- 438
- Rate of flu vaccination
- 98.6
- Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
- Number of potentially preventable readmissions following discharge
- 48
- Number of eligible stays
- 755
- Unadjusted potentially preventable readmission rate
- 6.36
- Risk-standardized potentially preventable readmission rate (RSRR)
- 8.27
- Lower limit of the 95% confidence interval on the RSRR
- 6.86
- Upper limit of the 95% confidence interval on the RSRR
- 10.09
- Comparative performance category
- No Different than the National Rate
- Rate of potentially preventable hospital readmissions during the IRF stay
- Number of potentially preventable readmissions
- 27
- Number of eligible stays
- 809
- Unadjusted potentially preventable readmission rate
- 3.34
- Risk-standardized potentially preventable readmission rate (RSRR)
- 4.10
- Lower limit of the 95% confidence interval on the RSRR
- 3.32
- Upper limit of the 95% confidence interval on the RSRR
- 5.22
- 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)
- 466
- Number of eligible stays
- 643
- Observed discharge to community rate
- 72.47
- Risk-standardized discharge to community rate
- 71.96
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 68.90
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 74.93
- Comparative performance category
- Better than the National Rate
- Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
- MSPB score
- 0.92
- Number of eligible episodes
- 735
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 863
- Denominator
- 872
- Facility rate
- 99.0
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 15
- Denominator
- 872
- Facility observed rate
- 1.7
- Facility risk-adjusted rate
- 1.7
- Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
- Number of health care workers vaccinated
- 183
- Number of health care workers
- 184
- Rate of COVID-19 vaccination
- 99.5