JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

San Luis Valley Regional Medical Center

3 / 5

At a glance

San Luis Valley Regional Medical Center carries a 3-star CMS overall rating — in line with the national norm.

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 LimitNot available
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence LimitNot available
Central Line Associated Bloodstream Infection: Number of Device Days574Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases0.454Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases0Not available
Central Line Associated Bloodstream Infection (ICU + select Wards)Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence LimitNot available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence LimitNot available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days808Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases0.596Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases1Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards)Not available
SSI - Colon Surgery: Lower Confidence LimitNot available
SSI - Colon Surgery: Upper Confidence LimitNot available
SSI - Colon Surgery: Number of Procedures28Not available
SSI - Colon Surgery: Predicted Cases0.695Not available
SSI - Colon Surgery: Observed Cases1Not available
SSI - Colon SurgeryNot available
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures3Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.028Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitNot available
MRSA Bacteremia: Upper Confidence LimitNot available
MRSA Bacteremia: Patient Days6200Not available
MRSA Bacteremia: Predicted Cases0.206Not available
MRSA Bacteremia: Observed Cases0Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence Limit0.312Same as national
Clostridium Difficile (C.Diff): Upper Confidence Limit3.335Same as national
Clostridium Difficile (C.Diff): Patient Days5599Same as national
Clostridium Difficile (C.Diff): Predicted Cases2.448Same as national
Clostridium Difficile (C.Diff): Observed Cases3Same as national
Clostridium Difficile (C.Diff)1.225Same as 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 patients3.9Same as national97
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4.6Same as national168
Death rate for heart attack patientsNot available
Death rate for CABG surgery patientsNot available
Death rate for COPD patientsNot available
Death rate for heart failure patientsNot available
Death rate for pneumonia patients16.8Same as national47
Death rate for stroke patientsNot available
Pressure ulcer rate0.52Same as national500
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.21Same as national637
In-hospital fall-associated fracture rate0.27Same as national598
Postoperative hemorrhage or hematoma rate2.62Same as national192
Postoperative acute kidney injury requiring dialysis rate1.67Same as national98
Postoperative respiratory failure rate9.01Same as national92
Perioperative pulmonary embolism or deep vein thrombosis rate3.71Same as national194
Postoperative sepsis rate5.15Same as national94
Postoperative wound dehiscence rate1.75Same as national42
Abdominopelvic accidental puncture or laceration rate1.04Same as national74
CMS Medicare PSI 90: Patient safety and adverse events composite0.96Same 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 patientsNot available
Hospital return days for heart failure patientsNot available
Hospital return days for pneumonia patients38.6Not available44
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)15.5Same as national221
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)13.3Same as national370
Rate of inpatient admissions for patients receiving outpatient chemotherapy10.4Same as national66
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy5.7Same as national66
Ratio of unplanned hospital visits after hospital outpatient surgery1Same as national141
Acute Myocardial Infarction (AMI) 30-Day Readmission RateNot available
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patientsNot available
Heart failure (HF) 30-Day Readmission RateNot available
Rate of readmission after hip/knee replacement4.9Same as national99
Pneumonia (PN) 30-Day Readmission Rate16Same as national44

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 rating4209
Doctor communication - star rating3209
Communication about medicines - star rating3209
Discharge information - star rating3209
Cleanliness - star rating4209
Quietness - star rating4209
Overall hospital rating - star rating2209
Recommend hospital - star rating3209
Summary star rating3209

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 volumelow
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 vaccination91915
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 better182425
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 better168367
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better28527
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better37833
Left before being seen114230
Head CT results
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients94284
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing8464
Appropriate care for severe sepsis and septic shock6984
Septic Shock 3-Hour Bundle8233
Septic Shock 6-Hour Bundle7818
Severe Sepsis 3-Hour Bundle8784
Severe Sepsis 6-Hour Bundle9048
Discharged on Antithrombotic Therapy
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 2
Venous Thromboembolism Prophylaxis79608
Intensive Care Unit Venous Thromboembolism Prophylaxis86199

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 San Luis Valley Regional Medical Center rated?
San Luis Valley Regional Medical Center has a 3 out of 5 CMS overall star rating as of the latest CMS release.
Does San Luis Valley Regional Medical Center have emergency services?
Yes. San Luis Valley Regional Medical Center operates a 24/7 emergency department.
Where is San Luis Valley Regional Medical Center located?
San Luis Valley Regional Medical Center is located at 106 Blanca Ave, Alamosa, CO 81101.
What type of hospital is San Luis Valley Regional Medical Center?
San Luis Valley Regional 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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