About the Facility
- CMS Certification Number (CCN)
- 673038
- Ownership Type
- Physician
- CMS Region
- Dallas
- Certification Date
- Address
21720 Kingsland Blvd, Suite 102
- Phone Number
- (281) 579-5678
Facility Medical Condition Statistics
- All other conditions
- 53
- Brain disease or condition (non-traumatic)
- 38
- Brain injury (traumatic)
- 33
- Hip or femur fracture
- 95
- Hip or knee replacement, amputation or other bone or joint condition
- 60
- Nervous system disorder (excluding stroke)
- 19
- Spinal cord disease or condition (non-traumatic)
- 33
- Spinal cord injury (traumatic)
- Data not available for this reporting period.
- Stroke
- 153
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
- 444
- Predicted number of infections (B)
- 0.791
- 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
- 482
- Denominator
- 482
- Facility rate
- 100.0
- Change in patients ability to care for themselves
- Average risk-adjusted change score
- 12.4
- Denominator
- 392
- Average observed change score
- 12.7
- Change in patients ability to move around
- Average risk-adjusted change score
- 30.0
- Denominator
- 392
- Average observed change score
- 29.7
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 219
- Denominator
- 392
- Facility rate
- 55.9
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 210
- Denominator
- 392
- Facility rate
- 53.6
- Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
- Numerator
- 0
- Denominator
- 482
- Facility rate
- 0.0
- Clostridium difficile Infection (CDI)
- Standardized infection ratio (SIR) 95% confidence interval - lower limit
- 0.027
- SIR 95% confidence interval - upper limit
- 2.615
- Comparative performance category
- No Different than the National Benchmark
- Patient days
- 8,795
- Predicted number of infections (B)
- 1.886
- Number of infections reported (A)
- 1
- SIR (A/B)
- 0.530
- Percentage of healthcare personnel who got a flu shot for the current season
- Number of health care workers vaccinated
- 447
- Number of health care workers
- 470
- Rate of flu vaccination
- 95.1
- Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
- Number of potentially preventable readmissions following discharge
- 40
- Number of eligible stays
- 519
- Unadjusted potentially preventable readmission rate
- 7.71
- Risk-standardized potentially preventable readmission rate (RSRR)
- 9.16
- Lower limit of the 95% confidence interval on the RSRR
- 7.45
- Upper limit of the 95% confidence interval on the RSRR
- 11.20
- Comparative performance category
- No Different than the National Rate
- Rate of potentially preventable hospital readmissions during the IRF stay
- Number of potentially preventable readmissions
- 40
- Number of eligible stays
- 589
- Unadjusted potentially preventable readmission rate
- 6.79
- Risk-standardized potentially preventable readmission rate (RSRR)
- 7.19
- Lower limit of the 95% confidence interval on the RSRR
- 5.48
- Upper limit of the 95% confidence interval on the RSRR
- 8.98
- Comparative performance category
- Worse than the National Rate
- Rate of successful return to home or community from an IRF
- Observed number of discharges to community (DTC)
- 325
- Number of eligible stays
- 481
- Observed discharge to community rate
- 67.57
- Risk-standardized discharge to community rate
- 65.63
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 61.82
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 69.00
- Comparative performance category
- No Different than the National Rate
- Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
- MSPB score
- 1.10
- Number of eligible episodes
- 544
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 479
- Denominator
- 482
- Facility rate
- 99.4
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 5
- Denominator
- 482
- Facility observed rate
- 1.0
- Facility risk-adjusted rate
- 0.9
- Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
- Number of health care workers vaccinated
- 310
- Number of health care workers
- 315
- Rate of COVID-19 vaccination
- 98.4