JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Southern Regional Medical Center

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At a glance

Southern Regional Medical Center carries a 1-star CMS overall rating — below 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 LimitSame as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit1.375Same as national
Central Line Associated Bloodstream Infection: Number of Device Days2340Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases2.179Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases0Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.000Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence LimitSame as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit2.244Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days1260Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases1.335Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases0Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.000Same as national
SSI - Colon Surgery: Lower Confidence LimitNot available
SSI - Colon Surgery: Upper Confidence LimitNot available
SSI - Colon Surgery: Number of Procedures33Not available
SSI - Colon Surgery: Predicted Cases0.970Not available
SSI - Colon Surgery: Observed Cases0Not available
SSI - Colon SurgeryNot available
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures11Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.078Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitSame as national
MRSA Bacteremia: Upper Confidence Limit1.637Same as national
MRSA Bacteremia: Patient Days28686Same as national
MRSA Bacteremia: Predicted Cases1.830Same as national
MRSA Bacteremia: Observed Cases0Same as national
MRSA Bacteremia0.000Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.004Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.345Better than national
Clostridium Difficile (C.Diff): Patient Days25310Better than national
Clostridium Difficile (C.Diff): Predicted Cases14.275Better than national
Clostridium Difficile (C.Diff): Observed Cases1Better than national
Clostridium Difficile (C.Diff)0.070Better 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 Rate5Same as national181
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 patients12.9Same as national56
Death rate for pneumonia patients18.2Same as national72
Death rate for stroke patients15Same as national31
Pressure ulcer rate0.33Same as national743
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.20Same as national1115
In-hospital fall-associated fracture rate0.26Same as national1137
Postoperative hemorrhage or hematoma rate2.27Same as national105
Postoperative acute kidney injury requiring dialysis rate1.65Same as national26
Postoperative respiratory failure rate11.72Same as national33
Perioperative pulmonary embolism or deep vein thrombosis rate3.32Same as national108
Postoperative sepsis rate6.03Same as national31
Postoperative wound dehiscence rate1.75Same as national33
Abdominopelvic accidental puncture or laceration rate1.01Same as national159
CMS Medicare PSI 90: Patient safety and adverse events composite0.98Same 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 patients48.3Not available72
Hospital return days for pneumonia patients86Not available68
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)15.5Same as national273
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)13.5Same as national30
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 national46
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 Rate20.5Same as national72
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate16.9Same as national68

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 rating1534
Doctor communication - star rating2534
Communication about medicines - star rating2534
Discharge information - star rating1534
Cleanliness - star rating1534
Quietness - star rating3534
Overall hospital rating - star rating1534
Recommend hospital - star rating1534
Summary star rating2534

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 Hypoglycemia21539
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination681042
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 better266423
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 better260387
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better69235
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 seen945404
Head CT results
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients8817
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing8928
Appropriate care for severe sepsis and septic shock4988
Septic Shock 3-Hour Bundle7322
Septic Shock 6-Hour Bundle8614
Severe Sepsis 3-Hour Bundle6288
Severe Sepsis 6-Hour Bundle8938
Discharged on Antithrombotic Therapy90124
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 293107
Venous Thromboembolism Prophylaxis
Intensive Care Unit Venous Thromboembolism Prophylaxis

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 MeasureNo

Frequently asked questions

How is Southern Regional Medical Center rated?
Southern Regional Medical Center has a 1 out of 5 CMS overall star rating as of the latest CMS release.
Does Southern Regional Medical Center have emergency services?
Yes. Southern Regional Medical Center operates a 24/7 emergency department.
Where is Southern Regional Medical Center located?
Southern Regional Medical Center is located at 11 Upper Riverdale Road, Sw, Riverdale, GA 30274.
What type of hospital is Southern Regional Medical Center?
Southern 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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