JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Saint Rose Dominican Hospitals - San Martin Campus

4 / 5

At a glance

Saint Rose Dominican Hospitals - San Martin Campus carries a 4-star CMS overall rating — above 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 Limit0.014Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit1.402Same as national
Central Line Associated Bloodstream Infection: Number of Device Days3823Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases3.519Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases1Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.284Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.019Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit1.907Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days2509Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases2.586Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases1Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.387Same as national
SSI - Colon Surgery: Lower Confidence Limit0.191Same as national
SSI - Colon Surgery: Upper Confidence Limit2.039Same as national
SSI - Colon Surgery: Number of Procedures152Same as national
SSI - Colon Surgery: Predicted Cases4.004Same as national
SSI - Colon Surgery: Observed Cases3Same as national
SSI - Colon Surgery0.749Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures7Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.061Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitSame as national
MRSA Bacteremia: Upper Confidence Limit2.308Same as national
MRSA Bacteremia: Patient Days27702Same as national
MRSA Bacteremia: Predicted Cases1.298Same as national
MRSA Bacteremia: Observed Cases0Same as national
MRSA Bacteremia0.000Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.028Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.554Better than national
Clostridium Difficile (C.Diff): Patient Days27702Better than national
Clostridium Difficile (C.Diff): Predicted Cases11.936Better 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 patientsNot available
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4.2Same as national696
Death rate for heart attack patients11.9Same as national59
Death rate for CABG surgery patients3.2Same as national88
Death rate for COPD patients7.9Same as national64
Death rate for heart failure patients12.1Same as national210
Death rate for pneumonia patients21Worse than national175
Death rate for stroke patients12.9Same as national58
Pressure ulcer rate0.25Same as national2322
Death rate among surgical inpatients with serious treatable complications170.84Same as national49
Iatrogenic pneumothorax rate0.29Same as national2850
In-hospital fall-associated fracture rate0.29Same as national3179
Postoperative hemorrhage or hematoma rate2.89Same as national684
Postoperative acute kidney injury requiring dialysis rate2.92Same as national369
Postoperative respiratory failure rate15.07Same as national354
Perioperative pulmonary embolism or deep vein thrombosis rate3.88Same as national753
Postoperative sepsis rate7.65Same as national360
Postoperative wound dehiscence rate1.68Same as national191
Abdominopelvic accidental puncture or laceration rate1.38Same as national643
CMS Medicare PSI 90: Patient safety and adverse events composite1.22Same 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-25.3Not available64
Hospital return days for heart failure patients-11.4Not available250
Hospital return days for pneumonia patients-1.7Not available193
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)15.4Same as national1063
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)13.3Same as national71
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 surgery1.1Same as national269
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate13.1Same as national64
Rate of readmission for CABG12.4Same as national86
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients17.7Same as national67
Heart failure (HF) 30-Day Readmission Rate20Same as national250
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate16.4Same as national193

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 rating4512
Doctor communication - star rating3512
Communication about medicines - star rating3512
Discharge information - star rating3512
Cleanliness - star rating3512
Quietness - star rating3512
Overall hospital rating - star rating4512
Recommend hospital - star rating5512
Summary star rating3512

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 Hyperglycemia
Hospital Harm - Severe Hypoglycemia
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination642148
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 better171393
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 better166359
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better27025
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 seen025025
Head CT results
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients4015
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing172123
Appropriate care for severe sepsis and septic shock57136
Septic Shock 3-Hour Bundle6144
Septic Shock 6-Hour Bundle8927
Severe Sepsis 3-Hour Bundle72136
Severe Sepsis 6-Hour Bundle9973
Discharged on Antithrombotic Therapy9087
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 2
Venous Thromboembolism Prophylaxis873693
Intensive Care Unit Venous Thromboembolism Prophylaxis98828

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 Saint Rose Dominican Hospitals - San Martin Campus rated?
Saint Rose Dominican Hospitals - San Martin Campus has a 4 out of 5 CMS overall star rating as of the latest CMS release.
Does Saint Rose Dominican Hospitals - San Martin Campus have emergency services?
Yes. Saint Rose Dominican Hospitals - San Martin Campus operates a 24/7 emergency department.
Where is Saint Rose Dominican Hospitals - San Martin Campus located?
Saint Rose Dominican Hospitals - San Martin Campus is located at 8280 W Warm Springs Road, Las Vegas, NV 89113.
What type of hospital is Saint Rose Dominican Hospitals - San Martin Campus?
Saint Rose Dominican Hospitals - San Martin Campus 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.

Report an issue with this page