JCIPatientSafety.orgHospital Quality Directory

Critical Access Hospitals · Voluntary non-profit - Private

Mercy Walworth Hospital & Medical Center

3 / 5

At a glance

Mercy Walworth Hospital & Medical Center carries a 3-star CMS overall rating — in line with 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 Days280Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases0.077Not 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 LimitNot available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence LimitNot available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days454Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases0.296Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases0Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards)Not available
SSI - Colon Surgery: Lower Confidence LimitNot available
SSI - Colon Surgery: Upper Confidence LimitNot available
SSI - Colon Surgery: Number of Procedures6Not available
SSI - Colon Surgery: Predicted Cases0.137Not available
SSI - Colon Surgery: Observed Cases0Not available
SSI - Colon SurgeryNot available
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures10Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.076Not 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 Days3458Not available
MRSA Bacteremia: Predicted Cases0.071Not available
MRSA Bacteremia: Observed Cases0Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence LimitSame as national
Clostridium Difficile (C.Diff): Upper Confidence Limit2.193Same as national
Clostridium Difficile (C.Diff): Patient Days3458Same as national
Clostridium Difficile (C.Diff): Predicted Cases1.366Same as national
Clostridium Difficile (C.Diff): Observed Cases0Same as national
Clostridium Difficile (C.Diff)0.000Same 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 patients4Same as national26
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate5.1Same as national210
Death rate for heart attack patientsNot available
Death rate for CABG surgery patientsNot available
Death rate for COPD patients9Same as national36
Death rate for heart failure patients11.4Same as national76
Death rate for pneumonia patients18.3Same as national61
Death rate for stroke patientsNot available
Pressure ulcer rateNot available
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rateNot available
In-hospital fall-associated fracture rateNot available
Postoperative hemorrhage or hematoma rateNot available
Postoperative acute kidney injury requiring dialysis rateNot available
Postoperative respiratory failure rateNot available
Perioperative pulmonary embolism or deep vein thrombosis rateNot available
Postoperative sepsis rateNot available
Postoperative wound dehiscence rateNot available
Abdominopelvic accidental puncture or laceration rateNot available
CMS Medicare PSI 90: Patient safety and adverse events compositeNot available

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 patients-35Not available95
Hospital return days for pneumonia patients31.9Not available71
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.7Same as national295
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)Not available
Rate of inpatient admissions for patients receiving outpatient chemotherapy10.1Same as national58
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy5.5Same as national58
Ratio of unplanned hospital visits after hospital outpatient surgeryNot available
Acute Myocardial Infarction (AMI) 30-Day Readmission RateNot available
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients18.7Same as national37
Heart failure (HF) 30-Day Readmission Rate18.1Same as national95
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate16.4Same as national71

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 rating4221
Doctor communication - star rating5221
Communication about medicines - star rating4221
Discharge information - star rating4221
Cleanliness - star rating4221
Quietness - star rating4221
Overall hospital rating - star rating4221
Recommend hospital - star rating4221
Summary star rating4221

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 volumelow
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 vaccination86487
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 better133595
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 better126540
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better24126
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better31432
Left before being seen010404
Head CT results4314
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients9489
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing10327
Appropriate care for severe sepsis and septic shock4122
Septic Shock 3-Hour Bundle
Septic Shock 6-Hour Bundle
Severe Sepsis 3-Hour Bundle8222
Severe Sepsis 6-Hour Bundle9315
Discharged on Antithrombotic Therapy
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 2
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 Walworth Hospital & Medical Center rated?
Mercy Walworth Hospital & Medical Center has a 3 out of 5 CMS overall star rating as of the latest CMS release.
Does Mercy Walworth Hospital & Medical Center have emergency services?
Yes. Mercy Walworth Hospital & Medical Center operates a 24/7 emergency department.
Where is Mercy Walworth Hospital & Medical Center located?
Mercy Walworth Hospital & Medical Center is located at N2950 State Road 67, Lake Geneva, WI 53147.
What type of hospital is Mercy Walworth Hospital & Medical Center?
Mercy Walworth Hospital & Medical Center is classified by CMS as a Critical Access 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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