JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Kenmore Mercy Hospital

3 / 5

At a glance

Kenmore Mercy Hospital carries a 3-star CMS overall rating — in line with the national norm. On healthcare-associated infection measures, it performs better than the national average on 6 and worse on 0.

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 Limit0.014Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit1.352Same as national
Central Line Associated Bloodstream Infection: Number of Device Days5403Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases3.648Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases1Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.274Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence LimitBetter than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit0.619Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days7182Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases4.836Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases0Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.000Better than national
SSI - Colon Surgery: Lower Confidence LimitSame as national
SSI - Colon Surgery: Upper Confidence Limit1.125Same as national
SSI - Colon Surgery: Number of Procedures107Same as national
SSI - Colon Surgery: Predicted Cases2.662Same as national
SSI - Colon Surgery: Observed Cases0Same as national
SSI - Colon Surgery0.000Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of ProceduresNot available
SSI - Abdominal Hysterectomy: Predicted CasesNot available
SSI - Abdominal Hysterectomy: Observed CasesNot available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence Limit0.028Same as national
MRSA Bacteremia: Upper Confidence Limit2.788Same as national
MRSA Bacteremia: Patient Days34954Same as national
MRSA Bacteremia: Predicted Cases1.769Same as national
MRSA Bacteremia: Observed Cases1Same as national
MRSA Bacteremia0.565Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.496Same as national
Clostridium Difficile (C.Diff): Upper Confidence Limit1.557Same as national
Clostridium Difficile (C.Diff): Patient Days34954Same as national
Clostridium Difficile (C.Diff): Predicted Cases13.101Same as national
Clostridium Difficile (C.Diff): Observed Cases12Same as national
Clostridium Difficile (C.Diff)0.916Same 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 Rate4.1Same as national547
Death rate for heart attack patients13.8Same as national40
Death rate for CABG surgery patientsNot available
Death rate for COPD patients11.3Same as national56
Death rate for heart failure patients16.5Worse than national145
Death rate for pneumonia patients18.5Same as national135
Death rate for stroke patients13.2Same as national51
Pressure ulcer rate0.33Same as national1785
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.19Same as national2284
In-hospital fall-associated fracture rate0.29Same as national2210
Postoperative hemorrhage or hematoma rate2.39Same as national482
Postoperative acute kidney injury requiring dialysis rate2.04Same as national231
Postoperative respiratory failure rate11.37Same as national235
Perioperative pulmonary embolism or deep vein thrombosis rate3.57Same as national497
Postoperative sepsis rate4.47Same as national212
Postoperative wound dehiscence rate1.67Same as national146
Abdominopelvic accidental puncture or laceration rate0.95Same as national375
CMS Medicare PSI 90: Patient safety and adverse events composite0.95Same 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 patients12.7Not available155
Hospital return days for pneumonia patients42Not available131
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.4Same as national814
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)12.9Same as national92
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 surgery0.9Same as national310
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate13.5Same as national27
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients19.1Same as national53
Heart failure (HF) 30-Day Readmission Rate19.6Same as national155
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate17.2Same as national131

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 rating4981
Doctor communication - star rating4981
Communication about medicines - star rating2981
Discharge information - star rating4981
Cleanliness - star rating3981
Quietness - star rating2981
Overall hospital rating - star rating4981
Recommend hospital - star rating5981
Summary star rating4981

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 volumemedium
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 Hypoglycemia
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination552767
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 better232387
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 better230367
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better24911
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 seen338385
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 Prescribing182265
Appropriate care for severe sepsis and septic shock29139
Septic Shock 3-Hour Bundle4328
Septic Shock 6-Hour Bundle
Severe Sepsis 3-Hour Bundle47139
Severe Sepsis 6-Hour Bundle9042
Discharged on Antithrombotic Therapy96113
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 2
Venous Thromboembolism Prophylaxis914219
Intensive Care Unit Venous Thromboembolism Prophylaxis95618

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 MeasureNot Applicable (our hospital does not provide inpatient labor/delivery care)

Frequently asked questions

How is Kenmore Mercy Hospital rated?
Kenmore Mercy Hospital has a 3 out of 5 CMS overall star rating as of the latest CMS release.
Does Kenmore Mercy Hospital have emergency services?
Yes. Kenmore Mercy Hospital operates a 24/7 emergency department.
Where is Kenmore Mercy Hospital located?
Kenmore Mercy Hospital is located at 2950 Elmwood Avenue, Kenmore, NY 14217.
What type of hospital is Kenmore Mercy Hospital?
Kenmore Mercy Hospital 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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