About the Facility
- CMS Certification Number (CCN)
- 45T670
- Ownership Type
- For Profit
- CMS Region
- Dallas
- Certification Date
- Address
605 Holderrieth Blvd
- Phone Number
- (281) 401-7803
Facility Medical Condition Statistics
- All other conditions
- 123
- Brain disease or condition (non-traumatic)
- 78
- Brain injury (traumatic)
- Data not available for this reporting period.
- Hip or femur fracture
- 64
- Hip or knee replacement, amputation or other bone or joint condition
- 42
- Nervous system disorder (excluding stroke)
- 36
- Spinal cord disease or condition (non-traumatic)
- Data not available for this reporting period.
- Spinal cord injury (traumatic)
- -
- Stroke
- 58
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
- 658
- Predicted number of infections (B)
- 0.949
- 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
- 326
- Denominator
- 326
- Facility rate
- 100.0
- Change in patients ability to care for themselves
- Average risk-adjusted change score
- 14.3
- Denominator
- 274
- Average observed change score
- 15.8
- Change in patients ability to move around
- Average risk-adjusted change score
- 38.1
- Denominator
- 274
- Average observed change score
- 39.0
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 210
- Denominator
- 274
- Facility rate
- 76.6
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 214
- Denominator
- 274
- Facility rate
- 78.1
- Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
- Numerator
- 0
- Denominator
- 326
- 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
- 1.338
- Comparative performance category
- No Different than the National Benchmark
- Patient days
- 5,634
- Predicted number of infections (B)
- 2.239
- 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
- 166
- Number of health care workers
- 227
- Rate of flu vaccination
- 73.1
- Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
- Number of potentially preventable readmissions following discharge
- 52
- Number of eligible stays
- 442
- Unadjusted potentially preventable readmission rate
- 11.76
- Risk-standardized potentially preventable readmission rate (RSRR)
- 9.36
- Lower limit of the 95% confidence interval on the RSRR
- 7.76
- Upper limit of the 95% confidence interval on the RSRR
- 11.23
- 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
- 494
- Unadjusted potentially preventable readmission rate
- 5.47
- Risk-standardized potentially preventable readmission rate (RSRR)
- 4.85
- Lower limit of the 95% confidence interval on the RSRR
- 3.77
- Upper limit of the 95% confidence interval on the RSRR
- 6.51
- 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)
- 227
- Number of eligible stays
- 369
- Observed discharge to community rate
- 61.52
- Risk-standardized discharge to community rate
- 65.37
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 60.56
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 69.64
- Comparative performance category
- No Different than the National Rate
- Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
- MSPB score
- 1.19
- Number of eligible episodes
- 429
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 325
- Denominator
- 326
- Facility rate
- 99.7
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 6
- Denominator
- 324
- Facility observed rate
- 1.9
- Facility risk-adjusted rate
- 1.5
- Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
- Number of health care workers vaccinated
- 34
- Number of health care workers
- 40
- Rate of COVID-19 vaccination
- 85.0