JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Mercy General Hospital

3 / 5

At a glance

Mercy General 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 24 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 Limit0.078Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit0.829Better than national
Central Line Associated Bloodstream Infection: Number of Device Days9073Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases9.844Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases3Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.305Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.163Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit0.986Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days8791Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases11.242Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases5Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.445Better than national
SSI - Colon Surgery: Lower Confidence Limit0.009Better than national
SSI - Colon Surgery: Upper Confidence Limit0.853Better than national
SSI - Colon Surgery: Number of Procedures199Better than national
SSI - Colon Surgery: Predicted Cases5.785Better than national
SSI - Colon Surgery: Observed Cases1Better than national
SSI - Colon Surgery0.173Better than national
SSI - Abdominal Hysterectomy: Lower Confidence Limit0.609Same as national
SSI - Abdominal Hysterectomy: Upper Confidence Limit6.516Same as national
SSI - Abdominal Hysterectomy: Number of Procedures145Same as national
SSI - Abdominal Hysterectomy: Predicted Cases1.253Same as national
SSI - Abdominal Hysterectomy: Observed Cases3Same as national
SSI - Abdominal Hysterectomy2.394Same as national
MRSA Bacteremia: Lower Confidence Limit0.394Same as national
MRSA Bacteremia: Upper Confidence Limit2.024Same as national
MRSA Bacteremia: Patient Days73357Same as national
MRSA Bacteremia: Predicted Cases6.165Same as national
MRSA Bacteremia: Observed Cases6Same as national
MRSA Bacteremia0.973Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.001Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.146Better than national
Clostridium Difficile (C.Diff): Patient Days72380Better than national
Clostridium Difficile (C.Diff): Predicted Cases33.737Better than national
Clostridium Difficile (C.Diff): Observed Cases1Better than national
Clostridium Difficile (C.Diff)0.030Better 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.

MeasureScoreCompared to nationalSample
Rate of complications for hip/knee replacement patients4.1Same as national97
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate3.8Same as national1330
Death rate for heart attack patients12Same as national385
Death rate for CABG surgery patients2Same as national108
Death rate for COPD patients10.1Same as national66
Death rate for heart failure patients12.4Same as national359
Death rate for pneumonia patients18.6Same as national227
Death rate for stroke patients13.2Same as national104
Pressure ulcer rate2.85Worse than national4531
Death rate among surgical inpatients with serious treatable complications166.19Same as national113
Iatrogenic pneumothorax rate0.19Same as national5509
In-hospital fall-associated fracture rate0.26Same as national6091
Postoperative hemorrhage or hematoma rate1.86Same as national1834
Postoperative acute kidney injury requiring dialysis rate1.42Same as national863
Postoperative respiratory failure rate6.67Same as national927
Perioperative pulmonary embolism or deep vein thrombosis rate2.93Same as national1995
Postoperative sepsis rate2.80Same as national914
Postoperative wound dehiscence rate1.60Same as national331
Abdominopelvic accidental puncture or laceration rate0.82Same as national1035
CMS Medicare PSI 90: Patient safety and adverse events composite1.43Worse than 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 patients20.4Not available469
Hospital return days for heart failure patients15Not available464
Hospital return days for pneumonia patients10.3Not available217
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.7Same as national2235
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)12.3Same as national405
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 national516
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate14.1Same as national469
Rate of readmission for CABG9.9Same as national105
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients18.3Same as national90
Heart failure (HF) 30-Day Readmission Rate20.9Same as national464
Rate of readmission after hip/knee replacement6.2Same as national105
Pneumonia (PN) 30-Day Readmission Rate15.9Same as national217

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 rating4498
Doctor communication - star rating4498
Communication about medicines - star rating3498
Discharge information - star rating4498
Cleanliness - star rating3498
Quietness - star rating3498
Overall hospital rating - star rating4498
Recommend hospital - star rating5498
Summary star rating4498

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 volumehigh
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 vaccination763587
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 better175385
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 better171363
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better31319
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 seen145755
Head CT results7315
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients8763
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing123619
Appropriate care for severe sepsis and septic shock76123
Septic Shock 3-Hour Bundle8234
Septic Shock 6-Hour Bundle9123
Severe Sepsis 3-Hour Bundle83123
Severe Sepsis 6-Hour Bundle9974
Discharged on Antithrombotic Therapy
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 288129
Venous Thromboembolism Prophylaxis987184
Intensive Care Unit Venous Thromboembolism Prophylaxis991762

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 Mercy General Hospital rated?
Mercy General Hospital has a 3 out of 5 CMS overall star rating as of the latest CMS release.
Does Mercy General Hospital have emergency services?
Yes. Mercy General Hospital operates a 24/7 emergency department.
Where is Mercy General Hospital located?
Mercy General Hospital is located at 4001 J St, Sacramento, CA 95819.
What type of hospital is Mercy General Hospital?
Mercy General 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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