JCIPatientSafety.orgHospital Quality Directory

Critical Access Hospitals · Voluntary non-profit - Private

Southwest Memorial Hospital

4 / 5

At a glance

Southwest Memorial Hospital carries a 4-star CMS overall rating — above 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 Days85Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases0.024Not 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 Days564Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases0.368Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases0Not 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 Procedures9Not available
SSI - Colon Surgery: Predicted Cases0.169Not 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 Procedures1Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.007Not 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 Days4294Not available
MRSA Bacteremia: Predicted Cases0.089Not available
MRSA Bacteremia: Observed Cases0Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence LimitSame as national
Clostridium Difficile (C.Diff): Upper Confidence Limit2.795Same as national
Clostridium Difficile (C.Diff): Patient Days3978Same as national
Clostridium Difficile (C.Diff): Predicted Cases1.072Same as national
Clostridium Difficile (C.Diff): Observed Cases0Same as national
Clostridium Difficile (C.Diff)0.000Same 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 patientsNot available
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4.1Same as national139
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 patients16.4Same as national33
Death rate for pneumonia patients15.2Same as national61
Death rate for stroke patients13.1Same as national29
Pressure ulcer rateNot available
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rateNot available
In-hospital fall-associated fracture rateNot available
Postoperative hemorrhage or hematoma rateNot available
Postoperative acute kidney injury requiring dialysis rateNot available
Postoperative respiratory failure rateNot available
Perioperative pulmonary embolism or deep vein thrombosis rateNot available
Postoperative sepsis rateNot available
Postoperative wound dehiscence rateNot available
Abdominopelvic accidental puncture or laceration rateNot available
CMS Medicare PSI 90: Patient safety and adverse events compositeNot available

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 patients0.5Not available31
Hospital return days for pneumonia patients-28Not available58
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.8Same as national195
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)12.9Same as national437
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 national72
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 Rate19.5Same as national31
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate15.3Same as national58

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 rating5100
Doctor communication - star rating5100
Communication about medicines - star rating4100
Discharge information - star rating5100
Cleanliness - star rating5100
Quietness - star rating4100
Overall hospital rating - star rating4100
Recommend hospital - star rating4100
Summary star rating5100

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 volume
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 vaccination98492
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 better109440
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 better101377
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better23149
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better42018
Left before being seen
Head CT results6015
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 Prescribing12284
Appropriate care for severe sepsis and septic shock7142
Septic Shock 3-Hour Bundle9315
Septic Shock 6-Hour Bundle10011
Severe Sepsis 3-Hour Bundle8642
Severe Sepsis 6-Hour Bundle8025
Discharged on Antithrombotic Therapy9330
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 210030
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 MeasureYes

Frequently asked questions

How is Southwest Memorial Hospital rated?
Southwest Memorial Hospital has a 4 out of 5 CMS overall star rating as of the latest CMS release.
Does Southwest Memorial Hospital have emergency services?
Yes. Southwest Memorial Hospital operates a 24/7 emergency department.
Where is Southwest Memorial Hospital located?
Southwest Memorial Hospital is located at 1311 N Mildred Rd, Cortez, CO 81321.
What type of hospital is Southwest Memorial Hospital?
Southwest Memorial Hospital is classified by CMS as a Critical Access 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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