About the Facility
- CMS Certification Number (CCN)
- 45T193
- Ownership Type
- Non-profit
- CMS Region
- Dallas
- Certification Date
- Address
6720 Bertner
- Phone Number
- (832) 355-6281
Facility Medical Condition Statistics
- All other conditions
- 32
- Brain disease or condition (non-traumatic)
- 11
- Brain injury (traumatic)
- Data not available for this reporting period.
- Hip or femur fracture
- 14
- Hip or knee replacement, amputation or other bone or joint condition
- 11
- Nervous system disorder (excluding stroke)
- 16
- Spinal cord disease or condition (non-traumatic)
- Data not available for this reporting period.
- Spinal cord injury (traumatic)
- -
- 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
- 170
- Predicted number of infections (B)
- 0.350
- 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
- 118
- Denominator
- 118
- Facility rate
- 100.0
- Change in patients ability to care for themselves
- Average risk-adjusted change score
- 11.3
- Denominator
- 105
- Average observed change score
- 13.0
- Change in patients ability to move around
- Average risk-adjusted change score
- 28.8
- Denominator
- 105
- Average observed change score
- 32.1
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 52
- Denominator
- 105
- Facility rate
- 49.5
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 54
- Denominator
- 105
- Facility rate
- 51.4
- Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
- Numerator
- 0
- Denominator
- 118
- 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
- 1.595
- Comparative performance category
- No Different than the National Benchmark
- Patient days
- 2,990
- Predicted number of infections (B)
- 1.878
- 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
- 893
- Number of health care workers
- 2,239
- Rate of flu vaccination
- 39.9
- Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
- Number of potentially preventable readmissions following discharge
- 11
- Number of eligible stays
- 157
- Unadjusted potentially preventable readmission rate
- 7.01
- Risk-standardized potentially preventable readmission rate (RSRR)
- 7.96
- Lower limit of the 95% confidence interval on the RSRR
- 6.17
- Upper limit of the 95% confidence interval on the RSRR
- 10.07
- Comparative performance category
- No Different than the National Rate
- Rate of potentially preventable hospital readmissions during the IRF stay
- Number of potentially preventable readmissions
- 12
- Number of eligible stays
- 185
- Unadjusted potentially preventable readmission rate
- 6.49
- Risk-standardized potentially preventable readmission rate (RSRR)
- 4.95
- Lower limit of the 95% confidence interval on the RSRR
- 3.68
- Upper limit of the 95% confidence interval on the RSRR
- 6.40
- 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)
- 102
- Number of eligible stays
- 142
- Observed discharge to community rate
- 71.83
- Risk-standardized discharge to community rate
- 71.80
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 65.65
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 77.75
- Comparative performance category
- No Different than the National Rate
- Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
- MSPB score
- 0.94
- Number of eligible episodes
- 156
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 117
- Denominator
- 118
- Facility rate
- 99.2
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 0
- Denominator
- 118
- 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
- Not Available
- Number of health care workers
- Not Available
- Rate of COVID-19 vaccination
- Not Available