Nexus Specialty Hospital the Woodlands


About the Facility

CMS Certification Number (CCN)
45TA57
Ownership Type
For Profit
CMS Region
Dallas
Certification Date
Address
9182 Six Pines Drive
Phone Number
(713) 364-0317

Facility Medical Condition Statistics

All other conditions
15
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
Data not available for this reporting period.

Facility Quality of Patient Care Measures

Catheter-associated urinary tract infections (CAUTI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.193
SIR 95% confidence interval - upper limit
3.798
Comparative performance category
No Different than the National Benchmark
Catheter days
984
Predicted number of infections (B)
1.740
Number of infections reported (A)
2
SIR (A/B)
1.149
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
53
Denominator
53
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
10.6
Denominator
41
Average observed change score
7.8
Change in patients ability to move around
Average risk-adjusted change score
27.3
Denominator
41
Average observed change score
19.3
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
18
Denominator
41
Facility rate
43.9
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
20
Denominator
41
Facility rate
48.8
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
53
Facility rate
0.0
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.130
SIR 95% confidence interval - upper limit
2.558
Comparative performance category
No Different than the National Benchmark
Patient days
4,496
Predicted number of infections (B)
2.584
Number of infections reported (A)
2
SIR (A/B)
0.774
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
210
Number of health care workers
325
Rate of flu vaccination
64.6
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
3
Number of eligible stays
50
Unadjusted potentially preventable readmission rate
6.00
Risk-standardized potentially preventable readmission rate (RSRR)
8.23
Lower limit of the 95% confidence interval on the RSRR
6.22
Upper limit of the 95% confidence interval on the RSRR
10.61
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
5
Number of eligible stays
59
Unadjusted potentially preventable readmission rate
8.47
Risk-standardized potentially preventable readmission rate (RSRR)
5.17
Lower limit of the 95% confidence interval on the RSRR
3.68
Upper limit of the 95% confidence interval on the RSRR
7.35
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)
24
Number of eligible stays
46
Observed discharge to community rate
52.17
Risk-standardized discharge to community rate
63.15
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
52.73
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
73.67
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
0.98
Number of eligible episodes
58
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
53
Denominator
53
Facility rate
100.0
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
0
Denominator
52
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
317
Number of health care workers
330
Rate of COVID-19 vaccination
96.1