About the Facility
- CMS Certification Number (CCN)
- 45T346
- Ownership Type
- Non-profit
- CMS Region
- Dallas
- Certification Date
- Address
3080 College St
- Phone Number
- (409) 212-5000
Facility Medical Condition Statistics
- All other conditions
- 54
- Brain disease or condition (non-traumatic)
- 16
- Brain injury (traumatic)
- Data not available for this reporting period.
- Hip or femur fracture
- 57
- Hip or knee replacement, amputation or other bone or joint condition
- 23
- Nervous system disorder (excluding stroke)
- 13
- Spinal cord disease or condition (non-traumatic)
- Data not available for this reporting period.
- Spinal cord injury (traumatic)
- -
- Stroke
- 49
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
- 172
- Predicted number of infections (B)
- 0.329
- Number of infections reported (A)
- 1
- SIR (A/B)
- Not Available
- Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
- Numerator
- 212
- Denominator
- 213
- Facility rate
- 99.5
- Change in patients ability to care for themselves
- Average risk-adjusted change score
- 11.3
- Denominator
- 182
- Average observed change score
- 10.9
- Change in patients ability to move around
- Average risk-adjusted change score
- 25.4
- Denominator
- 182
- Average observed change score
- 26.6
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 96
- Denominator
- 182
- Facility rate
- 52.7
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 70
- Denominator
- 182
- Facility rate
- 38.5
- Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
- Numerator
- 0
- Denominator
- 213
- 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
- Not Available
- Comparative performance category
- Not Available
- Patient days
- 2,740
- Predicted number of infections (B)
- 0.731
- Number of infections reported (A)
- 1
- SIR (A/B)
- Not Available
- Percentage of healthcare personnel who got a flu shot for the current season
- Number of health care workers vaccinated
- 69
- Number of health care workers
- 70
- 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
- 15
- Number of eligible stays
- 228
- Unadjusted potentially preventable readmission rate
- 6.58
- Risk-standardized potentially preventable readmission rate (RSRR)
- 8.38
- Lower limit of the 95% confidence interval on the RSRR
- 6.62
- Upper limit of the 95% confidence interval on the RSRR
- 10.69
- Comparative performance category
- No Different than the National Rate
- Rate of potentially preventable hospital readmissions during the IRF stay
- Number of potentially preventable readmissions
- 11
- Number of eligible stays
- 247
- Unadjusted potentially preventable readmission rate
- 4.45
- Risk-standardized potentially preventable readmission rate (RSRR)
- 5.31
- Lower limit of the 95% confidence interval on the RSRR
- 3.67
- Upper limit of the 95% confidence interval on the RSRR
- 7.81
- 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)
- 127
- Number of eligible stays
- 198
- Observed discharge to community rate
- 64.14
- Risk-standardized discharge to community rate
- 61.77
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 56.24
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 66.71
- Comparative performance category
- Worse than the National Rate
- Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
- MSPB score
- 0.93
- Number of eligible episodes
- 224
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 208
- Denominator
- 213
- Facility rate
- 97.7
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 4
- Denominator
- 212
- Facility observed rate
- 1.9
- Facility risk-adjusted rate
- 1.9
- Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
- Number of health care workers vaccinated
- 522
- Number of health care workers
- 541
- Rate of COVID-19 vaccination
- 96.5