About the Facility
- CMS Certification Number (CCN)
- 673074
- Ownership Type
- Non-profit
- CMS Region
- Dallas
- Certification Date
- Address
23621 Se H.k. Dodgen Loop
- Phone Number
- (254) 410-0555
Facility Medical Condition Statistics
- All other conditions
- 146
- Brain disease or condition (non-traumatic)
- 27
- Brain injury (traumatic)
- 26
- Hip or femur fracture
- 53
- Hip or knee replacement, amputation or other bone or joint condition
- 90
- Nervous system disorder (excluding stroke)
- 38
- Spinal cord disease or condition (non-traumatic)
- 13
- Spinal cord injury (traumatic)
- Data not available for this reporting period.
- Stroke
- 93
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
- 453
- Predicted number of infections (B)
- 0.702
- 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
- 463
- Denominator
- 470
- Facility rate
- 98.5
- Change in patients ability to care for themselves
- Average risk-adjusted change score
- 11.4
- Denominator
- 404
- Average observed change score
- 13.3
- Change in patients ability to move around
- Average risk-adjusted change score
- 32.6
- Denominator
- 404
- Average observed change score
- 34.7
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 204
- Denominator
- 404
- Facility rate
- 50.5
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 261
- Denominator
- 404
- Facility rate
- 64.6
- Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
- Numerator
- 1
- Denominator
- 470
- Facility rate
- 0.2
- Clostridium difficile Infection (CDI)
- Standardized infection ratio (SIR) 95% confidence interval - lower limit
- Not Available
- SIR 95% confidence interval - upper limit
- 0.789
- Comparative performance category
- Better than the National Benchmark
- Patient days
- 8,183
- Predicted number of infections (B)
- 3.799
- Number of infections reported (A)
- 0
- SIR (A/B)
- 0.000
- Percentage of healthcare personnel who got a flu shot for the current season
- Number of health care workers vaccinated
- 112
- Number of health care workers
- 115
- Rate of flu vaccination
- 97.4
- Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
- Number of potentially preventable readmissions following discharge
- 30
- Number of eligible stays
- 417
- Unadjusted potentially preventable readmission rate
- 7.19
- Risk-standardized potentially preventable readmission rate (RSRR)
- 8.20
- Lower limit of the 95% confidence interval on the RSRR
- 6.63
- Upper limit of the 95% confidence interval on the RSRR
- 10.16
- Comparative performance category
- No Different than the National Rate
- Rate of potentially preventable hospital readmissions during the IRF stay
- Number of potentially preventable readmissions
- 32
- Number of eligible stays
- 470
- Unadjusted potentially preventable readmission rate
- 6.81
- Risk-standardized potentially preventable readmission rate (RSRR)
- 6.40
- Lower limit of the 95% confidence interval on the RSRR
- 4.61
- Upper limit of the 95% confidence interval on the RSRR
- 7.88
- 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)
- 270
- Number of eligible stays
- 379
- Observed discharge to community rate
- 71.24
- Risk-standardized discharge to community rate
- 69.58
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 65.75
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 73.19
- Comparative performance category
- No Different than the National Rate
- Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
- MSPB score
- 1.08
- Number of eligible episodes
- 477
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 469
- Denominator
- 470
- Facility rate
- 99.8
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 13
- Denominator
- 469
- Facility observed rate
- 2.8
- Facility risk-adjusted rate
- 3.3
- Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
- Number of health care workers vaccinated
- 133
- Number of health care workers
- 134
- Rate of COVID-19 vaccination
- 99.3