JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Kaiser Foundation Hospital - San Marcos

4 / 5

At a glance

Kaiser Foundation Hospital - San Marcos carries a 4-star CMS overall rating — above the national norm.

Healthcare-Associated Infections

lower is better · 36 measures reported

Rates of infections patients can acquire while receiving care, such as central-line and catheter-associated infections, MRSA, and C. difficile.

MeasureScoreCompared to national
Central Line Associated Bloodstream Infection (ICU + select Wards): Lower Confidence Limit0.491Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit5.254Same as national
Central Line Associated Bloodstream Infection: Number of Device Days1716Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases1.554Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases3Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)1.931Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.020Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit1.970Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days2537Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases2.504Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases1Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.399Same as national
SSI - Colon Surgery: Lower Confidence Limit0.111Same as national
SSI - Colon Surgery: Upper Confidence Limit2.179Same as national
SSI - Colon Surgery: Number of Procedures125Same as national
SSI - Colon Surgery: Predicted Cases3.032Same as national
SSI - Colon Surgery: Observed Cases2Same as national
SSI - Colon Surgery0.660Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures7Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.056Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence Limit0.035Same as national
MRSA Bacteremia: Upper Confidence Limit3.444Same as national
MRSA Bacteremia: Patient Days32880Same as national
MRSA Bacteremia: Predicted Cases1.432Same as national
MRSA Bacteremia: Observed Cases1Same as national
MRSA Bacteremia0.698Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.423Same as national
Clostridium Difficile (C.Diff): Upper Confidence Limit1.218Same as national
Clostridium Difficile (C.Diff): Patient Days32069Same as national
Clostridium Difficile (C.Diff): Predicted Cases18.823Same as national
Clostridium Difficile (C.Diff): Observed Cases14Same as national
Clostridium Difficile (C.Diff)0.744Same as national

Complications & Deaths

lower is better · 20 measures reported

Rates of serious complications (like hip/knee replacement problems or accidental cuts during surgery) and 30-day mortality rates for common conditions.

MeasureScoreCompared to nationalSample
Rate of complications for hip/knee replacement patientsNot available
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4.3Same as national65
Death rate for heart attack patientsNot available
Death rate for CABG surgery patientsNot available
Death rate for COPD patientsNot available
Death rate for heart failure patientsNot available
Death rate for pneumonia patientsNot available
Death rate for stroke patientsNot available
Pressure ulcer rate0.60Same as national109
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.21Same as national152
In-hospital fall-associated fracture rate0.27Same as national155
Postoperative hemorrhage or hematoma rateNot available
Postoperative acute kidney injury requiring dialysis rateNot available
Postoperative respiratory failure rateNot available
Perioperative pulmonary embolism or deep vein thrombosis rateNot available
Postoperative sepsis rateNot available
Postoperative wound dehiscence rateNot available
Abdominopelvic accidental puncture or laceration rate1.05Same as national31
CMS Medicare PSI 90: Patient safety and adverse events composite0.99Same as national

Unplanned Hospital Visits & Readmissions

lower is better · 14 measures reported

How often patients return to the hospital unexpectedly within 30 days of discharge — a marker of care quality and discharge planning.

MeasureScoreCompared to nationalSample
Hospital return days for heart attack patientsNot available
Hospital return days for heart failure patientsNot available
Hospital return days for pneumonia patientsNot available
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)15.2Same as national99
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)Not available
Rate of inpatient admissions for patients receiving outpatient chemotherapyNot available
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapyNot available
Ratio of unplanned hospital visits after hospital outpatient surgeryNot available
Acute Myocardial Infarction (AMI) 30-Day Readmission RateNot available
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patientsNot available
Heart failure (HF) 30-Day Readmission RateNot available
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission RateNot available

Patient Experience (HCAHPS)

higher is better · 9 measures reported

What patients say about their hospital stay — communication with nurses and doctors, responsiveness, cleanliness, pain management, and whether they would recommend the hospital.

MeasureScoreSample
Nurse communication - star rating4549
Doctor communication - star rating4549
Communication about medicines - star rating4549
Discharge information - star rating5549
Cleanliness - star rating4549
Quietness - star rating4549
Overall hospital rating - star rating5549
Recommend hospital - star rating5549
Summary star rating4549

Timely & Effective Care

higher is better (unless a wait time) · 30 measures reported

How consistently hospitals follow recommended care processes — for example, giving heart-attack patients aspirin on arrival, or the average time spent in the emergency department.

MeasureScoreSample
Emergency department volume
Global Malnutrition Composite Score
Global Malnutrition Composite Score: Malnutrition Diagnosis Documented
Global Malnutrition Composite Score: Malnutrition Risk Screening
Global Malnutrition Composite Score: Nutrition Assessment
Global Malnutrition Composite Score: Nutritional Care Plan
Hospital Harm - Severe Hyperglycemia
Hospital Harm - Severe Hypoglycemia01579
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination782144
Average (median) time all patients spent in the emergency department before leaving from the visit, including psychiatric/mental health patients and patients who were transferred to another facility. A lower number of minutes is better
Average (median) time patients spent in the emergency department before leaving from the visit, excluding patients transferred to another facility or psychiatric care/mental health patients. A lower number of minutes is better
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better
Left before being seen
Head CT results
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing91879
Appropriate care for severe sepsis and septic shock76225
Septic Shock 3-Hour Bundle8567
Septic Shock 6-Hour Bundle9841
Severe Sepsis 3-Hour Bundle84225
Severe Sepsis 6-Hour Bundle97101
Discharged on Antithrombotic Therapy9584
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 2
Venous Thromboembolism Prophylaxis
Intensive Care Unit Venous Thromboembolism Prophylaxis

Maternal Health

lower is better · 4 measures reported

Measures of maternal outcomes and safe delivery practices, including severe complications during childbirth.

MeasureScoreSample
Cesarean Birth
Risk Adjusted Severe Obstetric Complications (All)
Risk Adjusted Severe Obstetric Complications (excluding blood-transfusion-only cases)
Maternal Morbidity Structural MeasureYes

Frequently asked questions

How is Kaiser Foundation Hospital - San Marcos rated?
Kaiser Foundation Hospital - San Marcos has a 4 out of 5 CMS overall star rating as of the latest CMS release.
Does Kaiser Foundation Hospital - San Marcos have emergency services?
Yes. Kaiser Foundation Hospital - San Marcos operates a 24/7 emergency department.
Where is Kaiser Foundation Hospital - San Marcos located?
Kaiser Foundation Hospital - San Marcos is located at 360 Rush Dr, San Marcos, CA 92078.
What type of hospital is Kaiser Foundation Hospital - San Marcos?
Kaiser Foundation Hospital - San Marcos is classified by CMS as a Acute Care Hospitals facility (Voluntary non-profit - Private).

Data as of 2026-06-14. Source: CMS Provider Data Catalog. This is public data provided for informational purposes only and is not medical advice. See our methodology and editorial policy.

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