Acute Care Hospitals · Voluntary non-profit - Private
Legacy Mount Hood Medical Center
- 24800 Se Stark Street, Gresham, OR 97030
- (503) 674-1122
- Acute Care Hospitals
- Emergency services available 24/7
At a glance
Legacy Mount Hood Medical Center 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.
| Measure | Score | Compared to national |
|---|---|---|
| Central Line Associated Bloodstream Infection (ICU + select Wards): Lower Confidence Limit | 0.176 | Same as national |
| Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit | 3.470 | Same as national |
| Central Line Associated Bloodstream Infection: Number of Device Days | 2756 | Same as national |
| Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases | 1.904 | Same as national |
| Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases | 2 | Same as national |
| Central Line Associated Bloodstream Infection (ICU + select Wards) | 1.050 | Same as national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit | 0.353 | Same as national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit | 3.775 | Same as national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days | 3039 | Same as national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases | 2.163 | Same as national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases | 3 | Same as national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards) | 1.387 | Same as national |
| SSI - Colon Surgery: Lower Confidence Limit | — | Same as national |
| SSI - Colon Surgery: Upper Confidence Limit | 1.086 | Same as national |
| SSI - Colon Surgery: Number of Procedures | 104 | Same as national |
| SSI - Colon Surgery: Predicted Cases | 2.758 | Same as national |
| SSI - Colon Surgery: Observed Cases | 0 | Same as national |
| SSI - Colon Surgery | 0.000 | Same as national |
| SSI - Abdominal Hysterectomy: Lower Confidence Limit | — | Not available |
| SSI - Abdominal Hysterectomy: Upper Confidence Limit | — | Not available |
| SSI - Abdominal Hysterectomy: Number of Procedures | 9 | Not available |
| SSI - Abdominal Hysterectomy: Predicted Cases | 0.089 | Not available |
| SSI - Abdominal Hysterectomy: Observed Cases | 0 | Not available |
| SSI - Abdominal Hysterectomy | — | Not available |
| MRSA Bacteremia: Lower Confidence Limit | — | Not available |
| MRSA Bacteremia: Upper Confidence Limit | — | Not available |
| MRSA Bacteremia: Patient Days | 25952 | Not available |
| MRSA Bacteremia: Predicted Cases | 0.997 | Not available |
| MRSA Bacteremia: Observed Cases | 1 | Not available |
| MRSA Bacteremia | — | Not available |
| Clostridium Difficile (C.Diff): Lower Confidence Limit | 0.139 | Better than national |
| Clostridium Difficile (C.Diff): Upper Confidence Limit | 0.843 | Better than national |
| Clostridium Difficile (C.Diff): Patient Days | 25952 | Better than national |
| Clostridium Difficile (C.Diff): Predicted Cases | 13.149 | Better than national |
| Clostridium Difficile (C.Diff): Observed Cases | 5 | Better than national |
| Clostridium Difficile (C.Diff) | 0.380 | Better than 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.
| Measure | Score | Compared to national | Sample |
|---|---|---|---|
| Rate of complications for hip/knee replacement patients | — | Not available | — |
| Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate | 3.9 | Same as national | 360 |
| Death rate for heart attack patients | 12.5 | Same as national | 40 |
| Death rate for CABG surgery patients | — | Not available | — |
| Death rate for COPD patients | 8.9 | Same as national | 52 |
| Death rate for heart failure patients | 12.9 | Same as national | 162 |
| Death rate for pneumonia patients | 16.6 | Same as national | 103 |
| Death rate for stroke patients | 10.9 | Same as national | 64 |
| Pressure ulcer rate | 1.14 | Same as national | 1325 |
| Death rate among surgical inpatients with serious treatable complications | — | Not available | — |
| Iatrogenic pneumothorax rate | 0.19 | Same as national | 1662 |
| In-hospital fall-associated fracture rate | 0.30 | Same as national | 1692 |
| Postoperative hemorrhage or hematoma rate | 2.16 | Same as national | 274 |
| Postoperative acute kidney injury requiring dialysis rate | 1.61 | Same as national | 81 |
| Postoperative respiratory failure rate | 7.78 | Same as national | 91 |
| Perioperative pulmonary embolism or deep vein thrombosis rate | 5.24 | Same as national | 287 |
| Postoperative sepsis rate | 4.79 | Same as national | 74 |
| Postoperative wound dehiscence rate | 2.06 | Same as national | 109 |
| Abdominopelvic accidental puncture or laceration rate | 1.18 | Same as national | 359 |
| CMS Medicare PSI 90: Patient safety and adverse events composite | 1.16 | Same 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.
| Measure | Score | Compared to national | Sample |
|---|---|---|---|
| Hospital return days for heart attack patients | — | Not available | — |
| Hospital return days for heart failure patients | 23.1 | Not available | 179 |
| Hospital return days for pneumonia patients | 3.4 | Not available | 104 |
| Hybrid Hospital-Wide All-Cause Readmission Measure (HWR) | 14.4 | Same as national | 535 |
| Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies) | 12.1 | Same as national | 738 |
| Rate of inpatient admissions for patients receiving outpatient chemotherapy | — | Not available | — |
| Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy | — | Not available | — |
| Ratio of unplanned hospital visits after hospital outpatient surgery | 1 | Same as national | 252 |
| Acute Myocardial Infarction (AMI) 30-Day Readmission Rate | — | Not available | — |
| Rate of readmission for CABG | — | Not available | — |
| Rate of readmission for chronic obstructive pulmonary disease (COPD) patients | 17.6 | Same as national | 50 |
| Heart failure (HF) 30-Day Readmission Rate | 19.4 | Same as national | 179 |
| Rate of readmission after hip/knee replacement | — | Not available | — |
| Pneumonia (PN) 30-Day Readmission Rate | 15.6 | Same as national | 104 |
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.
| Measure | Score | Sample |
|---|---|---|
| Nurse communication - star rating | 3 | 765 |
| Doctor communication - star rating | 3 | 765 |
| Communication about medicines - star rating | 3 | 765 |
| Discharge information - star rating | 3 | 765 |
| Cleanliness - star rating | 3 | 765 |
| Quietness - star rating | 2 | 765 |
| Overall hospital rating - star rating | 3 | 765 |
| Recommend hospital - star rating | 4 | 765 |
| Summary star rating | 3 | 765 |
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.
| Measure | Score | Sample |
|---|---|---|
| Emergency department volume | high | — |
| 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 | 1 | 1541 |
| Hospital Harm - Opioid Related Adverse Events | — | — |
| Healthcare workers given influenza vaccination | 51 | 1448 |
| 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 | 158 | 410 |
| 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 | 154 | 387 |
| Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better | 290 | 20 |
| 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 | 3 | 57667 |
| Head CT results | 65 | 20 |
| Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients | 99 | 75 |
| Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery | — | — |
| ST-Segment Elevation Myocardial Infarction (STEMI) | 11 | 27 |
| Safe Use of Opioids - Concurrent Prescribing | 12 | 1246 |
| Appropriate care for severe sepsis and septic shock | 27 | 108 |
| Septic Shock 3-Hour Bundle | 44 | 16 |
| Septic Shock 6-Hour Bundle | — | — |
| Severe Sepsis 3-Hour Bundle | 46 | 108 |
| Severe Sepsis 6-Hour Bundle | 59 | 27 |
| Discharged on Antithrombotic Therapy | 99 | 87 |
| Anticoagulation Therapy for Atrial Fibrillation/Flutter | — | — |
| Antithrombotic Therapy by End of Hospital Day 2 | 99 | 71 |
| 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.
| Measure | Score | Sample |
|---|---|---|
| Cesarean Birth | — | — |
| Risk Adjusted Severe Obstetric Complications (All) | — | — |
| Risk Adjusted Severe Obstetric Complications (excluding blood-transfusion-only cases) | — | — |
| Maternal Morbidity Structural Measure | Yes | — |
Frequently asked questions
- How is Legacy Mount Hood Medical Center rated?
- Legacy Mount Hood Medical Center has a 3 out of 5 CMS overall star rating as of the latest CMS release.
- Does Legacy Mount Hood Medical Center have emergency services?
- Yes. Legacy Mount Hood Medical Center operates a 24/7 emergency department.
- Where is Legacy Mount Hood Medical Center located?
- Legacy Mount Hood Medical Center is located at 24800 Se Stark Street, Gresham, OR 97030.
- What type of hospital is Legacy Mount Hood Medical Center?
- Legacy Mount Hood Medical Center is classified by CMS as a Acute Care Hospitals facility (Voluntary non-profit - Private).
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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.