About the Facility
- CMS Certification Number (CCN)
- 45T358
- Ownership Type
- Non-profit
- CMS Region
- Dallas
- Certification Date
- Address
6447 Main Street
- Phone Number
- (713) 441-7132
Facility Medical Condition Statistics
- All other conditions
- 143
- Brain disease or condition (non-traumatic)
- 55
- Brain injury (traumatic)
- 18
- Hip or femur fracture
- Data not available for this reporting period.
- Hip or knee replacement, amputation or other bone or joint condition
- 59
- Nervous system disorder (excluding stroke)
- 63
- Spinal cord disease or condition (non-traumatic)
- 52
- Spinal cord injury (traumatic)
- Data not available for this reporting period.
- Stroke
- 83
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
- 445
- Predicted number of infections (B)
- 0.920
- 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
- 473
- Denominator
- 473
- Facility rate
- 100.0
- Change in patients ability to care for themselves
- Average risk-adjusted change score
- 10.2
- Denominator
- 400
- Average observed change score
- 9.7
- Change in patients ability to move around
- Average risk-adjusted change score
- 24.6
- Denominator
- 401
- Average observed change score
- 23.9
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 185
- Denominator
- 401
- Facility rate
- 46.1
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 158
- Denominator
- 401
- Facility rate
- 39.4
- Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
- Numerator
- 2
- Denominator
- 473
- Facility rate
- 0.4
- Clostridium difficile Infection (CDI)
- Standardized infection ratio (SIR) 95% confidence interval - lower limit
- 0.288
- SIR 95% confidence interval - upper limit
- 1.744
- Comparative performance category
- No Different than the National Benchmark
- Patient days
- 10,119
- Predicted number of infections (B)
- 6.355
- Number of infections reported (A)
- 5
- SIR (A/B)
- 0.787
- Percentage of healthcare personnel who got a flu shot for the current season
- Number of health care workers vaccinated
- 126
- Number of health care workers
- 131
- Rate of flu vaccination
- 96.2
- Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
- Number of potentially preventable readmissions following discharge
- 39
- Number of eligible stays
- 474
- Unadjusted potentially preventable readmission rate
- 8.23
- Risk-standardized potentially preventable readmission rate (RSRR)
- 8.27
- Lower limit of the 95% confidence interval on the RSRR
- 6.66
- Upper limit of the 95% confidence interval on the RSRR
- 10.06
- 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
- 534
- Unadjusted potentially preventable readmission rate
- 5.06
- Risk-standardized potentially preventable readmission rate (RSRR)
- 4.63
- Lower limit of the 95% confidence interval on the RSRR
- 3.56
- Upper limit of the 95% confidence interval on the RSRR
- 5.88
- 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)
- 282
- Number of eligible stays
- 420
- Observed discharge to community rate
- 67.14
- Risk-standardized discharge to community rate
- 70.22
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 66.09
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 74.28
- Comparative performance category
- No Different than the National Rate
- Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
- MSPB score
- 1.00
- Number of eligible episodes
- 451
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 473
- Denominator
- 473
- Facility rate
- 100.0
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 4
- Denominator
- 471
- Facility observed rate
- 0.8
- Facility risk-adjusted rate
- 1.0
- Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
- Number of health care workers vaccinated
- 76
- Number of health care workers
- 77
- Rate of COVID-19 vaccination
- 98.7