JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Providence St Mary Medical Center

2 / 5

At a glance

Providence St Mary Medical Center carries a 2-star CMS overall rating — below the national norm. On healthcare-associated infection measures, it performs better than the national average on 12 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 Limit0.146Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit1.557Same as national
Central Line Associated Bloodstream Infection: Number of Device Days5555Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases5.243Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases3Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.572Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.010Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit0.960Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days4978Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases5.138Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases1Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.195Better than national
SSI - Colon Surgery: Lower Confidence Limit0.453Same as national
SSI - Colon Surgery: Upper Confidence Limit3.436Same as national
SSI - Colon Surgery: Number of Procedures101Same as national
SSI - Colon Surgery: Predicted Cases2.808Same as national
SSI - Colon Surgery: Observed Cases4Same as national
SSI - Colon Surgery1.425Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures39Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.348Not available
SSI - Abdominal Hysterectomy: Observed Cases1Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence Limit0.013Same as national
MRSA Bacteremia: Upper Confidence Limit1.318Same as national
MRSA Bacteremia: Patient Days69893Same as national
MRSA Bacteremia: Predicted Cases3.743Same as national
MRSA Bacteremia: Observed Cases1Same as national
MRSA Bacteremia0.267Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.174Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.610Better than national
Clostridium Difficile (C.Diff): Patient Days66414Better than national
Clostridium Difficile (C.Diff): Predicted Cases29.236Better than national
Clostridium Difficile (C.Diff): Observed Cases10Better than national
Clostridium Difficile (C.Diff)0.342Better 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 patients4.5Same as national28
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate3.6Same as national712
Death rate for heart attack patients11Same as national156
Death rate for CABG surgery patientsNot available
Death rate for COPD patients7.7Same as national50
Death rate for heart failure patients11Same as national273
Death rate for pneumonia patients15.3Same as national238
Death rate for stroke patients13Same as national119
Pressure ulcer rate0.85Same as national3539
Death rate among surgical inpatients with serious treatable complications149.35Same as national39
Iatrogenic pneumothorax rate0.23Same as national3834
In-hospital fall-associated fracture rate0.24Same as national4052
Postoperative hemorrhage or hematoma rate2.00Same as national604
Postoperative acute kidney injury requiring dialysis rate1.64Same as national103
Postoperative respiratory failure rate9.70Same as national117
Perioperative pulmonary embolism or deep vein thrombosis rate3.60Same as national586
Postoperative sepsis rate4.94Same as national104
Postoperative wound dehiscence rate1.69Same as national132
Abdominopelvic accidental puncture or laceration rate0.91Same as national557
CMS Medicare PSI 90: Patient safety and adverse events composite1.05Same 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 patients23.7Not available133
Hospital return days for heart failure patients36.9Not available313
Hospital return days for pneumonia patients32.5Not available256
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.2Same as national1107
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)12.8Same as national37
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 surgery0.9Same as national103
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate13.1Same as national133
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients17.7Same as national50
Heart failure (HF) 30-Day Readmission Rate20.6Same as national313
Rate of readmission after hip/knee replacement6.7Same as national27
Pneumonia (PN) 30-Day Readmission Rate16.8Same as national256

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 rating2456
Doctor communication - star rating2456
Communication about medicines - star rating1456
Discharge information - star rating2456
Cleanliness - star rating2456
Quietness - star rating1456
Overall hospital rating - star rating1456
Recommend hospital - star rating2456
Summary star rating2456

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 volumevery high
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 vaccination422118
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 better228382
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 better228352
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better17813
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better38617
Left before being seen188422
Head CT results94100
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing143320
Appropriate care for severe sepsis and septic shock56176
Septic Shock 3-Hour Bundle6459
Septic Shock 6-Hour Bundle8431
Severe Sepsis 3-Hour Bundle76178
Severe Sepsis 6-Hour Bundle9697
Discharged on Antithrombotic Therapy96321
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 294294
Venous Thromboembolism Prophylaxis
Intensive Care Unit Venous Thromboembolism Prophylaxis991513

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 St Mary Medical Center rated?
Providence St Mary Medical Center has a 2 out of 5 CMS overall star rating as of the latest CMS release.
Does Providence St Mary Medical Center have emergency services?
Yes. Providence St Mary Medical Center operates a 24/7 emergency department.
Where is Providence St Mary Medical Center located?
Providence St Mary Medical Center is located at 18300 Highway 18, Apple Valley, CA 92307.
What type of hospital is Providence St Mary Medical Center?
Providence St Mary Medical Center 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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