JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Providence Santa Rosa Memorial Hospital

3 / 5

At a glance

Providence Santa Rosa Memorial 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. For 30-day readmissions, it beats the national rate on 1 measure and trails 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 Limit0.232Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit1.758Same as national
Central Line Associated Bloodstream Infection: Number of Device Days5693Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases5.488Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases4Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.729Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.278Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit2.107Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days4665Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases4.579Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases4Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.874Same as national
SSI - Colon Surgery: Lower Confidence Limit0.671Same as national
SSI - Colon Surgery: Upper Confidence Limit3.443Same as national
SSI - Colon Surgery: Number of Procedures128Same as national
SSI - Colon Surgery: Predicted Cases3.625Same as national
SSI - Colon Surgery: Observed Cases6Same as national
SSI - Colon Surgery1.655Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures12Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.095Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence Limit0.012Same as national
MRSA Bacteremia: Upper Confidence Limit1.176Same as national
MRSA Bacteremia: Patient Days66142Same as national
MRSA Bacteremia: Predicted Cases4.193Same as national
MRSA Bacteremia: Observed Cases1Same as national
MRSA Bacteremia0.238Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.193Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.639Better than national
Clostridium Difficile (C.Diff): Patient Days63424Better than national
Clostridium Difficile (C.Diff): Predicted Cases29.902Better than national
Clostridium Difficile (C.Diff): Observed Cases11Better than national
Clostridium Difficile (C.Diff)0.368Better 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 patients3.5Same as national99
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate3.7Same as national1994
Death rate for heart attack patients13Same as national231
Death rate for CABG surgery patients2.2Same as national65
Death rate for COPD patients8Same as national115
Death rate for heart failure patients10.4Same as national556
Death rate for pneumonia patients14.7Same as national390
Death rate for stroke patients12.4Same as national284
Pressure ulcer rate0.46Same as national7051
Death rate among surgical inpatients with serious treatable complications181.27Same as national109
Iatrogenic pneumothorax rate0.22Same as national8115
In-hospital fall-associated fracture rate0.23Same as national8057
Postoperative hemorrhage or hematoma rate2.27Same as national1999
Postoperative acute kidney injury requiring dialysis rate1.59Same as national772
Postoperative respiratory failure rate5.74Same as national810
Perioperative pulmonary embolism or deep vein thrombosis rate2.37Same as national2186
Postoperative sepsis rate4.04Same as national768
Postoperative wound dehiscence rate1.80Same as national401
Abdominopelvic accidental puncture or laceration rate1.19Same as national1736
CMS Medicare PSI 90: Patient safety and adverse events composite0.76Same 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 patients-0.7Not available258
Hospital return days for heart failure patients2.3Not available602
Hospital return days for pneumonia patients27.6Not available378
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)13.5Better than national3282
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)13.5Same as national2810
Rate of inpatient admissions for patients receiving outpatient chemotherapy10.3Same as national584
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy6.4Same as national584
Ratio of unplanned hospital visits after hospital outpatient surgery1.2Same as national780
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate13.6Same as national258
Rate of readmission for CABG10.8Same as national64
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients17.9Same as national120
Heart failure (HF) 30-Day Readmission Rate18.5Same as national602
Rate of readmission after hip/knee replacement5Same as national96
Pneumonia (PN) 30-Day Readmission Rate16.6Same as national378

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 rating3505
Doctor communication - star rating2505
Communication about medicines - star rating2505
Discharge information - star rating3505
Cleanliness - star rating3505
Quietness - star rating1505
Overall hospital rating - star rating3505
Recommend hospital - star rating3505
Summary star rating3505

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 vaccination752501
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 better162379
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 better160342
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better37833
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 seen252273
Head CT results7731
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients9988
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing152886
Appropriate care for severe sepsis and septic shock60208
Septic Shock 3-Hour Bundle7166
Septic Shock 6-Hour Bundle8938
Severe Sepsis 3-Hour Bundle74209
Severe Sepsis 6-Hour Bundle94102
Discharged on Antithrombotic Therapy96168
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 288156
Venous Thromboembolism Prophylaxis
Intensive Care Unit Venous Thromboembolism Prophylaxis1001055

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 Providence Santa Rosa Memorial Hospital rated?
Providence Santa Rosa Memorial Hospital has a 3 out of 5 CMS overall star rating as of the latest CMS release.
Does Providence Santa Rosa Memorial Hospital have emergency services?
Yes. Providence Santa Rosa Memorial Hospital operates a 24/7 emergency department.
Where is Providence Santa Rosa Memorial Hospital located?
Providence Santa Rosa Memorial Hospital is located at 1165 Montgomery Dr, Santa Rosa, CA 95405.
What type of hospital is Providence Santa Rosa Memorial Hospital?
Providence Santa Rosa Memorial 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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