About the Facility
- CMS Certification Number (CCN)
- 45T229
- Ownership Type
- Non-profit
- CMS Region
- Dallas
- Certification Date
- Address
1934 Hickory
- Phone Number
- (915) 670-6000
Facility Medical Condition Statistics
- All other conditions
- 118
- Brain disease or condition (non-traumatic)
- 52
- Brain injury (traumatic)
- 24
- Hip or femur fracture
- 70
- Hip or knee replacement, amputation or other bone or joint condition
- 100
- Nervous system disorder (excluding stroke)
- 21
- Spinal cord disease or condition (non-traumatic)
- 42
- Spinal cord injury (traumatic)
- Data not available for this reporting period.
- Stroke
- 68
Facility Quality of Patient Care Measures
- Catheter-associated urinary tract infections (CAUTI)
- Standardized infection ratio (SIR) 95% confidence interval - lower limit
- 0.211
- SIR 95% confidence interval - upper limit
- 4.151
- Comparative performance category
- No Different than the National Benchmark
- Catheter days
- 769
- Predicted number of infections (B)
- 1.592
- Number of infections reported (A)
- 2
- SIR (A/B)
- 1.256
- Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
- Numerator
- 499
- Denominator
- 499
- Facility rate
- 100.0
- Change in patients ability to care for themselves
- Average risk-adjusted change score
- 11.5
- Denominator
- 445
- Average observed change score
- 13.2
- Change in patients ability to move around
- Average risk-adjusted change score
- 32.5
- Denominator
- 445
- Average observed change score
- 36.7
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 250
- Denominator
- 445
- Facility rate
- 56.2
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 291
- Denominator
- 445
- Facility rate
- 65.4
- Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
- Numerator
- 0
- Denominator
- 499
- Facility rate
- 0.0
- Clostridium difficile Infection (CDI)
- Standardized infection ratio (SIR) 95% confidence interval - lower limit
- 0.013
- SIR 95% confidence interval - upper limit
- 1.300
- Comparative performance category
- No Different than the National Benchmark
- Patient days
- 7,896
- Predicted number of infections (B)
- 3.794
- Number of infections reported (A)
- 1
- SIR (A/B)
- 0.264
- Percentage of healthcare personnel who got a flu shot for the current season
- Number of health care workers vaccinated
- 60
- Number of health care workers
- 69
- Rate of flu vaccination
- 87.0
- Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
- Number of potentially preventable readmissions following discharge
- 31
- Number of eligible stays
- 550
- Unadjusted potentially preventable readmission rate
- 5.64
- Risk-standardized potentially preventable readmission rate (RSRR)
- 7.94
- Lower limit of the 95% confidence interval on the RSRR
- 6.41
- Upper limit of the 95% confidence interval on the RSRR
- 9.80
- Comparative performance category
- No Different than the National Rate
- Rate of potentially preventable hospital readmissions during the IRF stay
- Number of potentially preventable readmissions
- 26
- Number of eligible stays
- 598
- Unadjusted potentially preventable readmission rate
- 4.35
- Risk-standardized potentially preventable readmission rate (RSRR)
- 5.54
- Lower limit of the 95% confidence interval on the RSRR
- 4.36
- Upper limit of the 95% confidence interval on the RSRR
- 7.59
- 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)
- 322
- Number of eligible stays
- 476
- Observed discharge to community rate
- 67.65
- Risk-standardized discharge to community rate
- 62.86
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 59.12
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 65.97
- Comparative performance category
- Worse than the National Rate
- Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
- MSPB score
- 1.07
- Number of eligible episodes
- 562
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 489
- Denominator
- 499
- Facility rate
- 98.0
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 12
- Denominator
- 499
- Facility observed rate
- 2.4
- Facility risk-adjusted rate
- 3.0
- Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
- Number of health care workers vaccinated
- 66
- Number of health care workers
- 84
- Rate of COVID-19 vaccination
- 78.6