JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Church

Mercy Regional Medical Center

5 / 5

At a glance

Mercy Regional Medical Center carries a 5-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 Limit0.028Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit2.779Same as national
Central Line Associated Bloodstream Infection: Number of Device Days2142Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases1.775Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases1Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.563Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.032Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit3.161Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days2041Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases1.560Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases1Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.641Same as national
SSI - Colon Surgery: Lower Confidence Limit0.033Same as national
SSI - Colon Surgery: Upper Confidence Limit3.279Same as national
SSI - Colon Surgery: Number of Procedures57Same as national
SSI - Colon Surgery: Predicted Cases1.504Same as national
SSI - Colon Surgery: Observed Cases1Same as national
SSI - Colon Surgery0.665Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures44Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.349Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitNot available
MRSA Bacteremia: Upper Confidence LimitNot available
MRSA Bacteremia: Patient Days18969Not available
MRSA Bacteremia: Predicted Cases0.805Not available
MRSA Bacteremia: Observed Cases0Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence Limit0.114Same as national
Clostridium Difficile (C.Diff): Upper Confidence Limit1.217Same as national
Clostridium Difficile (C.Diff): Patient Days17909Same as national
Clostridium Difficile (C.Diff): Predicted Cases6.710Same as national
Clostridium Difficile (C.Diff): Observed Cases3Same as national
Clostridium Difficile (C.Diff)0.447Same 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 Rate3.7Same as national737
Death rate for heart attack patients10.3Same as national133
Death rate for CABG surgery patientsNot available
Death rate for COPD patients9.3Same as national29
Death rate for heart failure patients13.8Same as national212
Death rate for pneumonia patients13.8Same as national146
Death rate for stroke patients12.7Same as national55
Pressure ulcer rate0.30Same as national1752
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.23Same as national2495
In-hospital fall-associated fracture rate0.25Same as national2477
Postoperative hemorrhage or hematoma rate2.34Same as national622
Postoperative acute kidney injury requiring dialysis rate1.55Same as national268
Postoperative respiratory failure rate6.38Same as national262
Perioperative pulmonary embolism or deep vein thrombosis rate2.98Same as national693
Postoperative sepsis rate5.27Same as national260
Postoperative wound dehiscence rate1.68Same as national211
Abdominopelvic accidental puncture or laceration rate0.95Same as national499
CMS Medicare PSI 90: Patient safety and adverse events composite0.79Same 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 patients-27.2Not available146
Hospital return days for heart failure patients-20.6Not available233
Hospital return days for pneumonia patients-24.4Not available154
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)13.7Same as national1055
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)12.9Same as national1306
Rate of inpatient admissions for patients receiving outpatient chemotherapy10.4Same as national215
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy6.9Same as national215
Ratio of unplanned hospital visits after hospital outpatient surgery1.1Same as national558
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate12.4Same as national146
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients17.7Same as national31
Heart failure (HF) 30-Day Readmission Rate17.9Same as national233
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate15.1Same as national154

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 rating4510
Doctor communication - star rating4510
Communication about medicines - star rating3510
Discharge information - star rating4510
Cleanliness - star rating3510
Quietness - star rating3510
Overall hospital rating - star rating4510
Recommend hospital - star rating4510
Summary star rating4510

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 Hypoglycemia1782
Hospital Harm - Opioid Related Adverse Events02375
Healthcare workers given influenza vaccination941280
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 better168405
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 better161359
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better20934
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better31314
Left before being seen123129
Head CT results7322
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients9575
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing141178
Appropriate care for severe sepsis and septic shock6474
Septic Shock 3-Hour Bundle8826
Septic Shock 6-Hour Bundle6718
Severe Sepsis 3-Hour Bundle8574
Severe Sepsis 6-Hour Bundle8548
Discharged on Antithrombotic Therapy
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 210042
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 Mercy Regional Medical Center rated?
Mercy Regional Medical Center has a 5 out of 5 CMS overall star rating as of the latest CMS release.
Does Mercy Regional Medical Center have emergency services?
Yes. Mercy Regional Medical Center operates a 24/7 emergency department.
Where is Mercy Regional Medical Center located?
Mercy Regional Medical Center is located at 1010 Three Springs Blvd, Durango, CO 81301.
What type of hospital is Mercy Regional Medical Center?
Mercy Regional Medical Center is classified by CMS as a Acute Care Hospitals facility (Voluntary non-profit - Church).

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.

Report an issue with this page