About the Facility
- CMS Certification Number (CCN)
- 45T862
- Ownership Type
- Non-profit
- CMS Region
- Dallas
- Certification Date
- Address
17200 St. Luke's Way
- Phone Number
- (502) 596-6346
Facility Medical Condition Statistics
- All other conditions
- 32
- Brain disease or condition (non-traumatic)
- Data not available for this reporting period.
- Brain injury (traumatic)
- Data not available for this reporting period.
- Hip or femur fracture
- Data not available for this reporting period.
- Hip or knee replacement, amputation or other bone or joint condition
- Data not available for this reporting period.
- Nervous system disorder (excluding stroke)
- Data not available for this reporting period.
- Spinal cord disease or condition (non-traumatic)
- Data not available for this reporting period.
- Spinal cord injury (traumatic)
- Data not available for this reporting period.
- Stroke
- 30
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
- 2.273
- Comparative performance category
- No Different than the National Benchmark
- Catheter days
- 645
- Predicted number of infections (B)
- 1.318
- Number of infections reported (A)
- 0
- SIR (A/B)
- 0.000
- Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
- Numerator
- 99
- Denominator
- 99
- Facility rate
- 100.0
- Change in patients ability to care for themselves
- Average risk-adjusted change score
- 15.2
- Denominator
- 86
- Average observed change score
- 15.0
- Change in patients ability to move around
- Average risk-adjusted change score
- 36.2
- Denominator
- 86
- Average observed change score
- 35.4
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 76
- Denominator
- 86
- Facility rate
- 88.4
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 70
- Denominator
- 86
- Facility rate
- 81.4
- Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
- Numerator
- 0
- Denominator
- 99
- 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
- 1,863
- Predicted number of infections (B)
- 0.638
- Number of infections reported (A)
- 0
- SIR (A/B)
- Not Available
- Percentage of healthcare personnel who got a flu shot for the current season
- Number of health care workers vaccinated
- 26
- Number of health care workers
- 45
- Rate of flu vaccination
- 57.8
- Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
- Number of potentially preventable readmissions following discharge
- 7
- Number of eligible stays
- 79
- Unadjusted potentially preventable readmission rate
- 8.86
- Risk-standardized potentially preventable readmission rate (RSRR)
- 8.61
- Lower limit of the 95% confidence interval on the RSRR
- 6.50
- Upper limit of the 95% confidence interval on the RSRR
- 11.06
- Comparative performance category
- No Different than the National Rate
- Rate of potentially preventable hospital readmissions during the IRF stay
- Number of potentially preventable readmissions
- 1
- Number of eligible stays
- 84
- Unadjusted potentially preventable readmission rate
- 1.19
- Risk-standardized potentially preventable readmission rate (RSRR)
- 4.25
- Lower limit of the 95% confidence interval on the RSRR
- 2.77
- Upper limit of the 95% confidence interval on the RSRR
- 6.60
- 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)
- 35
- Number of eligible stays
- 54
- Observed discharge to community rate
- 64.81
- Risk-standardized discharge to community rate
- 66.15
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 56.99
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 73.53
- Comparative performance category
- No Different than the National Rate
- Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
- MSPB score
- 1.05
- Number of eligible episodes
- 80
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 95
- Denominator
- 99
- Facility rate
- 96.0
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 1
- Denominator
- 99
- Facility observed rate
- 1.0
- Facility risk-adjusted rate
- 1.0
- Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
- Number of health care workers vaccinated
- 34
- Number of health care workers
- 43
- Rate of COVID-19 vaccination
- 79.1