JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Montefiore Mount Vernon Hospital

3 / 5

At a glance

Montefiore Mount Vernon 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 6 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 LimitNot available
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence LimitNot available
Central Line Associated Bloodstream Infection: Number of Device Days450Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases0.268Not 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 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 Days465Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases0.234Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases1Not 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 Procedures14Not available
SSI - Colon Surgery: Predicted Cases0.361Not 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 ProceduresNot available
SSI - Abdominal Hysterectomy: Predicted CasesNot available
SSI - Abdominal Hysterectomy: Observed CasesNot available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitNot available
MRSA Bacteremia: Upper Confidence LimitNot available
MRSA Bacteremia: Patient Days12294Not available
MRSA Bacteremia: Predicted Cases0.404Not available
MRSA Bacteremia: Observed Cases1Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence LimitBetter than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.651Better than national
Clostridium Difficile (C.Diff): Patient Days12294Better than national
Clostridium Difficile (C.Diff): Predicted Cases4.600Better than national
Clostridium Difficile (C.Diff): Observed Cases0Better than national
Clostridium Difficile (C.Diff)0.000Better 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 patientsNot available
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4.1Same as national101
Death rate for heart attack patientsNot available
Death rate for CABG surgery patientsNot available
Death rate for COPD patientsNot available
Death rate for heart failure patients9.8Same as national25
Death rate for pneumonia patients15.2Same as national27
Death rate for stroke patientsNot available
Pressure ulcer rate0.54Same as national378
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.21Same as national484
In-hospital fall-associated fracture rate0.27Same as national486
Postoperative hemorrhage or hematoma rate2.32Same as national25
Postoperative acute kidney injury requiring dialysis rateNot available
Postoperative respiratory failure rateNot available
Perioperative pulmonary embolism or deep vein thrombosis rate3.49Same as national26
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 composite0.97Same 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 patientsNot available
Hospital return days for pneumonia patients-24.8Not available28
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.9Same as national140
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)Not available
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 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) patientsNot available
Heart failure (HF) 30-Day Readmission RateNot available
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate15.5Same as national28

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 rating2175
Doctor communication - star rating2175
Communication about medicines - star rating2175
Discharge information - star rating2175
Cleanliness - star rating4175
Quietness - star rating3175
Overall hospital rating - star rating2175
Recommend hospital - star rating2175
Summary star rating2175

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 vaccination72591
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 better202408
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 better194362
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better25835
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better52613
Left before being seen118115
Head CT results
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients67113
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing14394
Appropriate care for severe sepsis and septic shock2934
Septic Shock 3-Hour Bundle
Septic Shock 6-Hour Bundle
Severe Sepsis 3-Hour Bundle5334
Severe Sepsis 6-Hour Bundle6916
Discharged on Antithrombotic Therapy10025
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 28131
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 MeasureNot Applicable (our hospital does not provide inpatient labor/delivery care)

Frequently asked questions

How is Montefiore Mount Vernon Hospital rated?
Montefiore Mount Vernon Hospital has a 3 out of 5 CMS overall star rating as of the latest CMS release.
Does Montefiore Mount Vernon Hospital have emergency services?
Yes. Montefiore Mount Vernon Hospital operates a 24/7 emergency department.
Where is Montefiore Mount Vernon Hospital located?
Montefiore Mount Vernon Hospital is located at 12 North 7th Avenue, Mount Vernon, NY 10550.
What type of hospital is Montefiore Mount Vernon Hospital?
Montefiore Mount Vernon 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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