About the Facility
- CMS Certification Number (CCN)
- 45TA39
- Ownership Type
- For Profit
- CMS Region
- Dallas
- Certification Date
- Address
11297 Fallbrook
- Phone Number
- (281) 897-8114
Facility Medical Condition Statistics
- All other conditions
- 29
- Brain disease or condition (non-traumatic)
- 12
- Brain injury (traumatic)
- -
- 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)
- 31
- Spinal cord disease or condition (non-traumatic)
- -
- Spinal cord injury (traumatic)
- Data not available for this reporting period.
- Stroke
- 16
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
- 80
- Predicted number of infections (B)
- 0.166
- 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
- 97
- Denominator
- 97
- Facility rate
- 100.0
- Change in patients ability to care for themselves
- Average risk-adjusted change score
- 12.5
- Denominator
- 75
- Average observed change score
- 11.1
- Change in patients ability to move around
- Average risk-adjusted change score
- 29.0
- Denominator
- 75
- Average observed change score
- 24.8
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 46
- Denominator
- 75
- Facility rate
- 61.3
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 43
- Denominator
- 75
- Facility rate
- 57.3
- Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
- Numerator
- 1
- Denominator
- 97
- Facility rate
- 1.0
- 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
- 925
- Predicted number of infections (B)
- 0.300
- Number of infections reported (A)
- 2
- SIR (A/B)
- Not Available
- Percentage of healthcare personnel who got a flu shot for the current season
- Number of health care workers vaccinated
- 22
- Number of health care workers
- 26
- Rate of flu vaccination
- 84.6
- Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
- Number of potentially preventable readmissions following discharge
- Not Available
- Number of eligible stays
- Not Available
- Unadjusted potentially preventable readmission rate
- Not Available
- Risk-standardized potentially preventable readmission rate (RSRR)
- Not Available
- Lower limit of the 95% confidence interval on the RSRR
- Not Available
- Upper limit of the 95% confidence interval on the RSRR
- Not Available
- Comparative performance category
- Not Available
- Rate of potentially preventable hospital readmissions during the IRF stay
- Number of potentially preventable readmissions
- Not Available
- Number of eligible stays
- Not Available
- Unadjusted potentially preventable readmission rate
- Not Available
- Risk-standardized potentially preventable readmission rate (RSRR)
- Not Available
- Lower limit of the 95% confidence interval on the RSRR
- Not Available
- Upper limit of the 95% confidence interval on the RSRR
- Not Available
- Comparative performance category
- Not Available
- Rate of successful return to home or community from an IRF
- Observed number of discharges to community (DTC)
- Not Available
- Number of eligible stays
- Not Available
- Observed discharge to community rate
- Not Available
- Risk-standardized discharge to community rate
- Not Available
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- Not Available
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- Not Available
- Comparative performance category
- Not Available
- Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
- MSPB score
- Not Available
- Number of eligible episodes
- Not Available
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 97
- Denominator
- 97
- Facility rate
- 100.0
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 0
- Denominator
- 96
- Facility observed rate
- 0.0
- Facility risk-adjusted rate
- 0.0
- Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
- Number of health care workers vaccinated
- 23
- Number of health care workers
- 25
- Rate of COVID-19 vaccination
- 92.0