Address
17200 St. Luke's Way
-
The Woodlands, TX 77384
Contact
(502) 596-6346
Certification Date
07/01/2016
CMS Certification Number
45T862
Ownership Type
Non-profit
| Condition | Count | Footnote |
|---|---|---|
| All other conditions | 32 | - |
| Brain disease or condition (non-traumatic) | Less than 11 | 1 |
| Brain injury (traumatic) | Less than 11 | 1 |
| Hip or femur fracture | Less than 11 | 1 |
| Hip or knee replacement, amputation or other bone or joint condition | Less than 11 | 1 |
| Nervous system disorder (excluding stroke) | Less than 11 | 1 |
| Spinal cord disease or condition (non-traumatic) | Less than 11 | 1 |
| Spinal cord injury (traumatic) | Less than 11 | 1 |
| Stroke | 30 | - |
Catheter-associated urinary tract infections (CAUTI) - Standardized infection ratio (SIR) 95% confidence interval - lower limit
Not Available
6
Other Measure
2.273
-
Catheter-associated urinary tract infections (CAUTI) - Comparative performance category
No Different than the National Benchmark
-
Catheter-associated urinary tract infections (CAUTI) - Catheter days
645
-
Catheter-associated urinary tract infections (CAUTI) - Predicted number of infections (B)
1.318
-
Catheter-associated urinary tract infections (CAUTI) - Number of infections reported (A)
0
-
Catheter-associated urinary tract infections (CAUTI)
0.000
-
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan - Denominator
99
-
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan - Numerator
99
-
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
100.0
-
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay - Denominator
99
-
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay - Numerator
0
-
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
0.0
-
Change in patients' ability to care for themselves
15.2
-
Change in patients' ability to care for themselves - Denominator
86
-
Change in patients' ability to care for themselves - Average observed change score
15.0
-
Change in patients' ability to move around
36.2
-
Change in patients' ability to move around - Denominator
86
-
Change in patients' ability to move around - Average observed change score
35.4
-
Percentage of patients who are at or above an expected ability to care for themselves at discharge - Denominator
86
-
Percentage of patients who are at or above an expected ability to care for themselves at discharge - Numerator
76
-
Percentage of patients who are at or above an expected ability to care for themselves at discharge
88.4
-
Percentage of patients who are at or above an expected ability to care for themselves at discharge - Denominator
86
-
Percentage of patients who are at or above an expected ability to care for themselves at discharge - Numerator
70
-
Percentage of patients who are at or above an expected ability to move around at discharge
81.4
-
Clostridium difficile Infection (CDI) - Standardized infection ratio (SIR) 95% confidence interval - lower limit
Not Available
6,7
Clostridium difficile Infection (CDI) - SIR 95% confidence interval - upper limit
Not Available
6,7
Clostridium difficile Infection (CDI) - Comparative performance category
Not Available
6,7
Clostridium difficile Infection (CDI) - Patient days
1,863
-
Clostridium difficile Infection (CDI) - Predicted number of infections (B)
0.638
-
Clostridium difficile Infection (CDI) - Number of infections reported (A)
0
-
Clostridium difficile Infection (CDI)
Not Available
6,7
Percentage of healthcare personnel who got a flu shot for the current season - Number of health care workers
45
-
Percentage of healthcare personnel who got a flu shot for the current season - Number of health care workers vaccinated
26
-
Percentage of healthcare personnel who got a flu shot for the current season
57.8
-
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF - Comparative performance category
No Different than the National Rate
-
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF - Unadjusted potentially preventable readmission rate
8.86
-
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF - Number of potentially preventable readmissions following discharge
7
-
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
8.61
-
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF - Lower limit of the 95% confidence interval on the RSRR
6.50
-
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF - Upper limit of the 95% confidence interval on the RSRR
11.06
-
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF - Number of eligible stays
79
-
Rate of potentially preventable hospital readmissions during the IRF stay - Comparative performance category
No Different than the National Rate
-
Rate of potentially preventable hospital readmissions during the IRF stay - Unadjusted potentially preventable readmission rate
1.19
-
Rate of potentially preventable hospital readmissions during the IRF stay - Number of potentially preventable readmissions
1
-
Rate of potentially preventable hospital readmissions during the IRF stay
4.25
-
Rate of potentially preventable hospital readmissions during the IRF stay - Lower limit of the 95% confidence interval on the RSRR
2.77
-
Rate of potentially preventable hospital readmissions during the IRF stay - Upper limit of the 95% confidence interval on the RSRR
6.60
-
Rate of potentially preventable hospital readmissions during the IRF stay - Number of eligible stays
84
-
Rate of successful return to home or community from an IRF - 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)
35
-
Rate of successful return to home or community from an IRF - Observed discharge to community rate
64.81
-
Rate of successful return to home or community from an IRF
66.15
-
Rate of successful return to home or community from an IRF - Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
56.99
-
Rate of successful return to home or community from an IRF - Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
73.53
-
Rate of successful return to home or community from an IRF - Number of eligible stays
54
-
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs - Number of eligible episodes
80
-
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
1.05
-
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified - Denominator
99
-
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified - Numerator
95
-
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
96.0
-
Other Measure
1.0
-
Other Measure
99
-
Other Measure
1
-
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
1.0
-
Other Measure
43
-
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series - Number of health care workers vaccinated
34
-
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
79.1
-