JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Saint Rose Dominican Hospitals - Siena Campus

3 / 5

At a glance

Saint Rose Dominican Hospitals - Siena Campus 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 24 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 Limit0.194Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit0.994Better than national
Central Line Associated Bloodstream Infection: Number of Device Days14980Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases12.557Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases6Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.478Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.005Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit0.527Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days10860Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases9.358Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases1Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.107Better than national
SSI - Colon Surgery: Lower Confidence Limit0.391Same as national
SSI - Colon Surgery: Upper Confidence Limit2.005Same as national
SSI - Colon Surgery: Number of Procedures239Same as national
SSI - Colon Surgery: Predicted Cases6.225Same as national
SSI - Colon Surgery: Observed Cases6Same as national
SSI - Colon Surgery0.964Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures81Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.697Not available
SSI - Abdominal Hysterectomy: Observed Cases2Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence Limit0.045Better than national
MRSA Bacteremia: Upper Confidence Limit0.884Better than national
MRSA Bacteremia: Patient Days105130Better than national
MRSA Bacteremia: Predicted Cases7.477Better than national
MRSA Bacteremia: Observed Cases2Better than national
MRSA Bacteremia0.267Better than national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.137Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.430Better than national
Clostridium Difficile (C.Diff): Patient Days98659Better than national
Clostridium Difficile (C.Diff): Predicted Cases47.439Better than national
Clostridium Difficile (C.Diff): Observed Cases12Better than national
Clostridium Difficile (C.Diff)0.253Better 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 national245
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4.5Same as national2283
Death rate for heart attack patients12.3Same as national241
Death rate for CABG surgery patients4Same as national100
Death rate for COPD patients9.4Same as national158
Death rate for heart failure patients11.2Same as national579
Death rate for pneumonia patients15.1Same as national685
Death rate for stroke patients11.9Same as national233
Pressure ulcer rate0.23Same as national8032
Death rate among surgical inpatients with serious treatable complications158.25Same as national158
Iatrogenic pneumothorax rate0.25Same as national8723
In-hospital fall-associated fracture rate0.23Same as national9335
Postoperative hemorrhage or hematoma rate1.79Same as national1923
Postoperative acute kidney injury requiring dialysis rate1.77Same as national718
Postoperative respiratory failure rate11.27Same as national768
Perioperative pulmonary embolism or deep vein thrombosis rate3.38Same as national2152
Postoperative sepsis rate8.18Same as national732
Postoperative wound dehiscence rate1.54Same as national437
Abdominopelvic accidental puncture or laceration rate0.97Same as national1840
CMS Medicare PSI 90: Patient safety and adverse events composite1.02Same 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 patients1.1Not available248
Hospital return days for heart failure patients17.1Not available686
Hospital return days for pneumonia patients31.9Not available701
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)15.2Same as national3791
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)14.3Same as national475
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 national643
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate12.9Same as national248
Rate of readmission for CABG8.4Same as national95
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients17Same as national168
Heart failure (HF) 30-Day Readmission Rate20.5Same as national686
Rate of readmission after hip/knee replacement4.5Same as national202
Pneumonia (PN) 30-Day Readmission Rate18.1Worse than national701

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 rating3420
Doctor communication - star rating2420
Communication about medicines - star rating2420
Discharge information - star rating3420
Cleanliness - star rating2420
Quietness - star rating3420
Overall hospital rating - star rating3420
Recommend hospital - star rating3420
Summary star rating3420

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 vaccination704338
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 better181392
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 better175365
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better28419
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 seen175920
Head CT results
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients3033
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing135097
Appropriate care for severe sepsis and septic shock66142
Septic Shock 3-Hour Bundle6546
Septic Shock 6-Hour Bundle9627
Severe Sepsis 3-Hour Bundle80142
Severe Sepsis 6-Hour Bundle10078
Discharged on Antithrombotic Therapy93296
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 2
Venous Thromboembolism Prophylaxis799918
Intensive Care Unit Venous Thromboembolism Prophylaxis931829

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 Saint Rose Dominican Hospitals - Siena Campus rated?
Saint Rose Dominican Hospitals - Siena Campus has a 3 out of 5 CMS overall star rating as of the latest CMS release.
Does Saint Rose Dominican Hospitals - Siena Campus have emergency services?
Yes. Saint Rose Dominican Hospitals - Siena Campus operates a 24/7 emergency department.
Where is Saint Rose Dominican Hospitals - Siena Campus located?
Saint Rose Dominican Hospitals - Siena Campus is located at 3001 St Rose Parkway, Henderson, NV 89052.
What type of hospital is Saint Rose Dominican Hospitals - Siena Campus?
Saint Rose Dominican Hospitals - Siena 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.

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