About the Facility
- CMS Certification Number (CCN)
- 673071
- Ownership Type
- For Profit
- CMS Region
- Dallas
- Certification Date
- Address
23331 Grand Reserve Drive
- Phone Number
- (281) 505-3500
Facility Medical Condition Statistics
- All other conditions
- 75
- Brain disease or condition (non-traumatic)
- 49
- Brain injury (traumatic)
- 34
- Hip or femur fracture
- 103
- Hip or knee replacement, amputation or other bone or joint condition
- 207
- Nervous system disorder (excluding stroke)
- 519
- 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
- 166
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
- 911
- Predicted number of infections (B)
- 0.984
- Number of infections reported (A)
- 4
- SIR (A/B)
- Not Available
- Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
- Numerator
- 1,135
- Denominator
- 1,135
- Facility rate
- 100.0
- Change in patients ability to care for themselves
- Average risk-adjusted change score
- 15.6
- Denominator
- 1,002
- Average observed change score
- 16.1
- Change in patients ability to move around
- Average risk-adjusted change score
- 38.0
- Denominator
- 1,002
- Average observed change score
- 35.6
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 828
- Denominator
- 1,002
- Facility rate
- 82.6
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 803
- Denominator
- 1,002
- Facility rate
- 80.1
- Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
- Numerator
- 2
- Denominator
- 1,135
- Facility rate
- 0.2
- Clostridium difficile Infection (CDI)
- Standardized infection ratio (SIR) 95% confidence interval - lower limit
- 0.471
- SIR 95% confidence interval - upper limit
- 2.417
- Comparative performance category
- No Different than the National Benchmark
- Patient days
- 14,942
- Predicted number of infections (B)
- 5.163
- Number of infections reported (A)
- 6
- SIR (A/B)
- 1.162
- Percentage of healthcare personnel who got a flu shot for the current season
- Number of health care workers vaccinated
- 361
- Number of health care workers
- 454
- Rate of flu vaccination
- 79.5
- Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
- Number of potentially preventable readmissions following discharge
- 88
- Number of eligible stays
- 895
- Unadjusted potentially preventable readmission rate
- 9.83
- Risk-standardized potentially preventable readmission rate (RSRR)
- 8.92
- Lower limit of the 95% confidence interval on the RSRR
- 7.55
- Upper limit of the 95% confidence interval on the RSRR
- 10.34
- Comparative performance category
- No Different than the National Rate
- Rate of potentially preventable hospital readmissions during the IRF stay
- Number of potentially preventable readmissions
- 61
- Number of eligible stays
- 998
- Unadjusted potentially preventable readmission rate
- 6.11
- Risk-standardized potentially preventable readmission rate (RSRR)
- 5.60
- Lower limit of the 95% confidence interval on the RSRR
- 4.43
- Upper limit of the 95% confidence interval on the RSRR
- 6.98
- 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)
- 560
- Number of eligible stays
- 775
- Observed discharge to community rate
- 72.26
- Risk-standardized discharge to community rate
- 73.92
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 70.78
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 76.95
- Comparative performance category
- Better than the National Rate
- Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
- MSPB score
- 1.01
- Number of eligible episodes
- 1,167
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 1,121
- Denominator
- 1,135
- Facility rate
- 98.8
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 10
- Denominator
- 1,132
- Facility observed rate
- 0.9
- Facility risk-adjusted rate
- 0.7
- Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
- Number of health care workers vaccinated
- 313
- Number of health care workers
- 325
- Rate of COVID-19 vaccination
- 96.3