JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Mclaren Lapeer Region

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At a glance

Mclaren Lapeer Region carries a 2-star CMS overall rating — below 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 LimitNot available
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence LimitNot available
Central Line Associated Bloodstream Infection: Number of Device Days868Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases0.654Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases1Not available
Central Line Associated Bloodstream Infection (ICU + select Wards)Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.270Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit5.312Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days1701Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases1.244Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases2Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)1.608Same as national
SSI - Colon Surgery: Lower Confidence LimitSame as national
SSI - Colon Surgery: Upper Confidence Limit2.351Same as national
SSI - Colon Surgery: Number of Procedures45Same as national
SSI - Colon Surgery: Predicted Cases1.274Same 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 Procedures37Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.331Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence Limit0.252Same as national
MRSA Bacteremia: Upper Confidence Limit4.961Same as national
MRSA Bacteremia: Patient Days24590Same as national
MRSA Bacteremia: Predicted Cases1.332Same as national
MRSA Bacteremia: Observed Cases2Same as national
MRSA Bacteremia1.502Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.473Same as national
Clostridium Difficile (C.Diff): Upper Confidence Limit1.661Same as national
Clostridium Difficile (C.Diff): Patient Days24343Same as national
Clostridium Difficile (C.Diff): Predicted Cases10.730Same as national
Clostridium Difficile (C.Diff): Observed Cases10Same as national
Clostridium Difficile (C.Diff)0.932Same 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 national650
Death rate for heart attack patients12.5Same as national66
Death rate for CABG surgery patientsNot available
Death rate for COPD patients9.7Same as national66
Death rate for heart failure patients12.6Same as national240
Death rate for pneumonia patients18.8Same as national183
Death rate for stroke patients12.9Same as national86
Pressure ulcer rate1.06Same as national2069
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.19Same as national2692
In-hospital fall-associated fracture rate0.25Same as national2679
Postoperative hemorrhage or hematoma rate2.18Same as national322
Postoperative acute kidney injury requiring dialysis rate1.66Same as national50
Postoperative respiratory failure rate11.58Same as national51
Perioperative pulmonary embolism or deep vein thrombosis rate3.95Same as national325
Postoperative sepsis rate5.15Same as national48
Postoperative wound dehiscence rate1.73Same as national92
Abdominopelvic accidental puncture or laceration rate0.98Same as national448
CMS Medicare PSI 90: Patient safety and adverse events composite1.18Same 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 patients2.3Not available261
Hospital return days for pneumonia patients21.9Not available195
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.6Same as national1003
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)13.2Same as national79
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 surgery1Same as national108
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate13.1Same as national29
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients18.4Same as national69
Heart failure (HF) 30-Day Readmission Rate19.2Same as national261
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate16.3Same as national195

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 rating3510
Doctor communication - star rating2510
Communication about medicines - star rating1510
Discharge information - star rating2510
Cleanliness - star rating1510
Quietness - star rating1510
Overall hospital rating - star rating1510
Recommend hospital - star rating1510
Summary star rating2510

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 vaccination531052
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 better193385
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 better186351
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better25927
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 seen220931
Head CT results
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients8266
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing131177
Appropriate care for severe sepsis and septic shock56147
Septic Shock 3-Hour Bundle7743
Septic Shock 6-Hour Bundle9030
Severe Sepsis 3-Hour Bundle67147
Severe Sepsis 6-Hour Bundle9967
Discharged on Antithrombotic Therapy93107
Anticoagulation Therapy for Atrial Fibrillation/Flutter5639
Antithrombotic Therapy by End of Hospital Day 29293
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 Mclaren Lapeer Region rated?
Mclaren Lapeer Region has a 2 out of 5 CMS overall star rating as of the latest CMS release.
Does Mclaren Lapeer Region have emergency services?
Yes. Mclaren Lapeer Region operates a 24/7 emergency department.
Where is Mclaren Lapeer Region located?
Mclaren Lapeer Region is located at 1375 N Main St, Lapeer, MI 48446.
What type of hospital is Mclaren Lapeer Region?
Mclaren Lapeer Region 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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