JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Nyack Hospital

2 / 5

At a glance

Nyack Hospital carries a 2-star CMS overall rating — below the national norm. On healthcare-associated infection measures, it performs better than the national average on 6 and worse on 0. For 30-day readmissions, it beats the national rate on 0 measures and trails on 1.

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 Limit0.081Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit1.591Same as national
Central Line Associated Bloodstream Infection: Number of Device Days5257Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases4.153Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases2Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.482Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.148Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit1.581Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days5797Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases5.164Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases3Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.581Same as national
SSI - Colon Surgery: Lower Confidence LimitSame as national
SSI - Colon Surgery: Upper Confidence Limit1.460Same as national
SSI - Colon Surgery: Number of Procedures88Same as national
SSI - Colon Surgery: Predicted Cases2.052Same as national
SSI - Colon Surgery: Observed Cases0Same as national
SSI - Colon Surgery0.000Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures29Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.216Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence Limit0.069Same as national
MRSA Bacteremia: Upper Confidence Limit1.368Same as national
MRSA Bacteremia: Patient Days67208Same as national
MRSA Bacteremia: Predicted Cases4.831Same as national
MRSA Bacteremia: Observed Cases2Same as national
MRSA Bacteremia0.414Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.019Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.200Better than national
Clostridium Difficile (C.Diff): Patient Days64017Better than national
Clostridium Difficile (C.Diff): Predicted Cases40.748Better than national
Clostridium Difficile (C.Diff): Observed Cases3Better than national
Clostridium Difficile (C.Diff)0.074Better 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 patients3Same as national145
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4Same as national1450
Death rate for heart attack patients10.8Same as national119
Death rate for CABG surgery patientsNot available
Death rate for COPD patients8.7Same as national111
Death rate for heart failure patients9.7Same as national310
Death rate for pneumonia patients15Same as national757
Death rate for stroke patients12.9Same as national151
Pressure ulcer rate0.34Same as national5496
Death rate among surgical inpatients with serious treatable complications187.07Same as national42
Iatrogenic pneumothorax rate0.16Same as national6177
In-hospital fall-associated fracture rate0.29Same as national6172
Postoperative hemorrhage or hematoma rate2.35Same as national775
Postoperative acute kidney injury requiring dialysis rate1.62Same as national216
Postoperative respiratory failure rate7.38Same as national222
Perioperative pulmonary embolism or deep vein thrombosis rate3.18Same as national807
Postoperative sepsis rate4.67Same as national209
Postoperative wound dehiscence rate1.64Same as national194
Abdominopelvic accidental puncture or laceration rate0.88Same as national974
CMS Medicare PSI 90: Patient safety and adverse events composite0.81Same 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 patients26.9Not available100
Hospital return days for heart failure patients4.1Not available334
Hospital return days for pneumonia patients64.4Not available752
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)16Same as national2350
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)12.9Same as national325
Rate of inpatient admissions for patients receiving outpatient chemotherapy12Same as national173
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy5.4Same as national173
Ratio of unplanned hospital visits after hospital outpatient surgery0.9Same as national471
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate14Same as national100
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients19.5Same as national130
Heart failure (HF) 30-Day Readmission Rate18.6Same as national334
Rate of readmission after hip/knee replacement5.9Same as national140
Pneumonia (PN) 30-Day Readmission Rate18.2Worse than national752

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 rating2988
Doctor communication - star rating2988
Communication about medicines - star rating2988
Discharge information - star rating1988
Cleanliness - star rating3988
Quietness - star rating2988
Overall hospital rating - star rating2988
Recommend hospital - star rating2988
Summary star rating2988

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 volumehigh
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 vaccination693105
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 better247585
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 better246546
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better23229
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better
Left before being seen353549
Head CT results6913
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients99149
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing161916
Appropriate care for severe sepsis and septic shock66274
Septic Shock 3-Hour Bundle8265
Septic Shock 6-Hour Bundle7850
Severe Sepsis 3-Hour Bundle83275
Severe Sepsis 6-Hour Bundle86167
Discharged on Antithrombotic Therapy98129
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 2
Venous Thromboembolism Prophylaxis994211
Intensive Care Unit Venous Thromboembolism Prophylaxis1002055

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 Nyack Hospital rated?
Nyack Hospital has a 2 out of 5 CMS overall star rating as of the latest CMS release.
Does Nyack Hospital have emergency services?
Yes. Nyack Hospital operates a 24/7 emergency department.
Where is Nyack Hospital located?
Nyack Hospital is located at 160 North Midland Avenue, Nyack, NY 10960.
What type of hospital is Nyack Hospital?
Nyack 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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