JCIPatientSafety.orgHospital Quality Directory

Critical Access Hospitals · Proprietary

Mimbres Valley Medical Center

Not rated overall

CMS reports safety and quality measures for this hospital but does not assign an overall star rating. See scores below.

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 Limit—Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit—Not available
Central Line Associated Bloodstream Infection: Number of Device Days234Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases0.063Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases0Not available
Central Line Associated Bloodstream Infection (ICU + select Wards)—Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.037Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit3.642Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days554Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases1.354Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases1Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.739Same as national
SSI - Colon Surgery: Lower Confidence Limit—Not available
SSI - Colon Surgery: Upper Confidence Limit—Not available
SSI - Colon Surgery: Number of Procedures5Not available
SSI - Colon Surgery: Predicted Cases0.138Not available
SSI - Colon Surgery: Observed Cases0Not available
SSI - Colon Surgery—Not available
SSI - Abdominal Hysterectomy: Lower Confidence Limit—Not available
SSI - Abdominal Hysterectomy: Upper Confidence Limit—Not available
SSI - Abdominal Hysterectomy: Number of Procedures—Not available
SSI - Abdominal Hysterectomy: Predicted Cases—Not available
SSI - Abdominal Hysterectomy: Observed Cases—Not available
SSI - Abdominal Hysterectomy—Not available
MRSA Bacteremia: Lower Confidence Limit—Not available
MRSA Bacteremia: Upper Confidence Limit—Not available
MRSA Bacteremia: Patient Days3053Not available
MRSA Bacteremia: Predicted Cases0.064Not available
MRSA Bacteremia: Observed Cases0Not available
MRSA Bacteremia—Not available
Clostridium Difficile (C.Diff): Lower Confidence Limit0.624Same as national
Clostridium Difficile (C.Diff): Upper Confidence Limit6.681Same as national
Clostridium Difficile (C.Diff): Patient Days3053Same as national
Clostridium Difficile (C.Diff): Predicted Cases1.222Same as national
Clostridium Difficile (C.Diff): Observed Cases3Same as national
Clostridium Difficile (C.Diff)2.455Same 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 patients—Not available—
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4.4Same as national72
Death rate for heart attack patients—Not available—
Death rate for CABG surgery patients—Not available—
Death rate for COPD patients—Not available—
Death rate for heart failure patients—Not available—
Death rate for pneumonia patients17Same as national35
Death rate for stroke patients—Not available—
Pressure ulcer rate—Not available—
Death rate among surgical inpatients with serious treatable complications—Not available—
Iatrogenic pneumothorax rate—Not available—
In-hospital fall-associated fracture rate—Not available—
Postoperative hemorrhage or hematoma rate—Not available—
Postoperative acute kidney injury requiring dialysis rate—Not available—
Postoperative respiratory failure rate—Not available—
Perioperative pulmonary embolism or deep vein thrombosis rate—Not available—
Postoperative sepsis rate—Not available—
Postoperative wound dehiscence rate—Not available—
Abdominopelvic accidental puncture or laceration rate—Not available—
CMS Medicare PSI 90: Patient safety and adverse events composite—Not 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 patients—Not available—
Hospital return days for heart failure patients—Not available—
Hospital return days for pneumonia patients54.4Not available34
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)15.3Same as national109
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)13.5Same as national36
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—Not available—
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—Not available—
Heart failure (HF) 30-Day Readmission Rate—Not available—
Rate of readmission after hip/knee replacement—Not available—
Pneumonia (PN) 30-Day Readmission Rate15.9Same as national34

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 rating3114
Doctor communication - star rating3114
Communication about medicines - star rating3114
Discharge information - star rating4114
Cleanliness - star rating4114
Quietness - star rating4114
Overall hospital rating - star rating4114
Recommend hospital - star rating3114
Summary star rating3114

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 Hypoglycemia2227
Hospital Harm - Opioid Related Adverse Events——
Healthcare workers given influenza vaccination66343
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 better156416
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 better139345
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better19026
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better33648
Left before being seen215127
Head CT results7713
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients9975
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery——
ST-Segment Elevation Myocardial Infarction (STEMI)——
Safe Use of Opioids - Concurrent Prescribing14130
Appropriate care for severe sepsis and septic shock89103
Septic Shock 3-Hour Bundle9842
Septic Shock 6-Hour Bundle8824
Severe Sepsis 3-Hour Bundle96103
Severe Sepsis 6-Hour Bundle9566
Discharged on Antithrombotic Therapy——
Anticoagulation Therapy for Atrial Fibrillation/Flutter——
Antithrombotic Therapy by End of Hospital Day 2——
Venous Thromboembolism Prophylaxis84446
Intensive Care Unit Venous Thromboembolism Prophylaxis85113

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 MeasureNo—

Frequently asked questions

How is Mimbres Valley Medical Center rated?
CMS does not assign an overall star rating to Mimbres Valley Medical Center, but does publish underlying safety and quality measures shown on this page.
Does Mimbres Valley Medical Center have emergency services?
Yes. Mimbres Valley Medical Center operates a 24/7 emergency department.
Where is Mimbres Valley Medical Center located?
Mimbres Valley Medical Center is located at 900 W Ash Street, Deming, NM 88031.
What type of hospital is Mimbres Valley Medical Center?
Mimbres Valley Medical Center is classified by CMS as a Critical Access Hospitals facility (Proprietary).

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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