JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Other

Nacogdoches Medical Center

3 / 5

At a glance

Nacogdoches Medical Center 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 Limit0.123Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit2.429Same as national
Central Line Associated Bloodstream Infection: Number of Device Days3943Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases2.720Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases2Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.735Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.011Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit1.094Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days6657Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases4.510Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases1Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.222Same as national
SSI - Colon Surgery: Lower Confidence Limit0.020Same as national
SSI - Colon Surgery: Upper Confidence Limit1.977Same as national
SSI - Colon Surgery: Number of Procedures94Same as national
SSI - Colon Surgery: Predicted Cases2.495Same as national
SSI - Colon Surgery: Observed Cases1Same as national
SSI - Colon Surgery0.401Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures31Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.281Not available
SSI - Abdominal Hysterectomy: Observed Cases1Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitNot available
MRSA Bacteremia: Upper Confidence LimitNot available
MRSA Bacteremia: Patient Days24737Not available
MRSA Bacteremia: Predicted Cases0.969Not available
MRSA Bacteremia: Observed Cases0Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence Limit0.028Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.557Better than national
Clostridium Difficile (C.Diff): Patient Days21422Better than national
Clostridium Difficile (C.Diff): Predicted Cases11.872Better than national
Clostridium Difficile (C.Diff): Observed Cases2Better than national
Clostridium Difficile (C.Diff)0.168Better 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 patients4Same as national81
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4.3Same as national646
Death rate for heart attack patients13.5Same as national91
Death rate for CABG surgery patientsNot available
Death rate for COPD patients9.6Same as national42
Death rate for heart failure patients8.8Same as national164
Death rate for pneumonia patients15.5Same as national290
Death rate for stroke patients13.3Same as national92
Pressure ulcer rate0.25Same as national2046
Death rate among surgical inpatients with serious treatable complications180.04Same as national39
Iatrogenic pneumothorax rate0.18Same as national2478
In-hospital fall-associated fracture rate0.24Same as national2529
Postoperative hemorrhage or hematoma rate2.32Same as national557
Postoperative acute kidney injury requiring dialysis rateNot available
Postoperative respiratory failure rateNot available
Perioperative pulmonary embolism or deep vein thrombosis rate4.78Same as national546
Postoperative sepsis rateNot available
Postoperative wound dehiscence rate2.36Same as national120
Abdominopelvic accidental puncture or laceration rate0.95Same as national299
CMS Medicare PSI 90: Patient safety and adverse events composite0.94Same 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 patients24.2Not available82
Hospital return days for heart failure patients-28Not available174
Hospital return days for pneumonia patients1.6Not available298
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)15.9Same as national980
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)12.7Same as national56
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 surgery1.2Same as national113
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate14Same as national82
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients18Same as national42
Heart failure (HF) 30-Day Readmission Rate19.8Same as national174
Rate of readmission after hip/knee replacement4.8Same as national72
Pneumonia (PN) 30-Day Readmission Rate16.4Same as national298

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 rating4605
Doctor communication - star rating4605
Communication about medicines - star rating3605
Discharge information - star rating3605
Cleanliness - star rating3605
Quietness - star rating4605
Overall hospital rating - star rating4605
Recommend hospital - star rating4605
Summary star rating4605

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 Hyperglycemia97645
Hospital Harm - Severe Hypoglycemia11240
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination711099
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 better156494
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 better151461
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better22111
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better43222
Left before being seen232998
Head CT results5618
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients8881
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing181201
Appropriate care for severe sepsis and septic shock6598
Septic Shock 3-Hour Bundle6237
Septic Shock 6-Hour Bundle10019
Severe Sepsis 3-Hour Bundle8798
Severe Sepsis 6-Hour Bundle9670
Discharged on Antithrombotic Therapy
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 2
Venous Thromboembolism Prophylaxis802669
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 Nacogdoches Medical Center rated?
Nacogdoches Medical Center has a 3 out of 5 CMS overall star rating as of the latest CMS release.
Does Nacogdoches Medical Center have emergency services?
Yes. Nacogdoches Medical Center operates a 24/7 emergency department.
Where is Nacogdoches Medical Center located?
Nacogdoches Medical Center is located at 4920 Ne Stallings Drive, Nacogdoches, TX 75965.
What type of hospital is Nacogdoches Medical Center?
Nacogdoches Medical Center is classified by CMS as a Acute Care Hospitals facility (Voluntary non-profit - Other).

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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