JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Proprietary

St Mary's General Hospital

3 / 5

At a glance

St Mary's General Hospital 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 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 Limit2.397Same as national
Central Line Associated Bloodstream Infection: Number of Device Days1325Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases1.250Same 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 Limit1.332Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days2212Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases2.249Same 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 Procedures36Not available
SSI - Colon Surgery: Predicted Cases0.854Not 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 Procedures65Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.441Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitSame as national
MRSA Bacteremia: Upper Confidence Limit2.045Same as national
MRSA Bacteremia: Patient Days24571Same as national
MRSA Bacteremia: Predicted Cases1.465Same as national
MRSA Bacteremia: Observed Cases0Same as national
MRSA Bacteremia0.000Same as national
Clostridium Difficile (C.Diff): Lower Confidence LimitBetter than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.314Better than national
Clostridium Difficile (C.Diff): Patient Days23614Better than national
Clostridium Difficile (C.Diff): Predicted Cases9.555Better than national
Clostridium Difficile (C.Diff): Observed Cases0Better than national
Clostridium Difficile (C.Diff)0.000Better 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 Rate3.9Same as national466
Death rate for heart attack patients11.1Same as national68
Death rate for CABG surgery patientsNot available
Death rate for COPD patients9.8Same as national33
Death rate for heart failure patients9.9Same as national188
Death rate for pneumonia patients15Same as national147
Death rate for stroke patients14.3Same as national32
Pressure ulcer rate0.27Same as national1693
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.18Same as national2153
In-hospital fall-associated fracture rate0.29Same as national2240
Postoperative hemorrhage or hematoma rate2.16Same as national333
Postoperative acute kidney injury requiring dialysis rate1.61Same as national72
Postoperative respiratory failure rate8.68Same as national88
Perioperative pulmonary embolism or deep vein thrombosis rate3.04Same as national358
Postoperative sepsis rate4.92Same as national72
Postoperative wound dehiscence rate1.74Same as national50
Abdominopelvic accidental puncture or laceration rate0.99Same as national295
CMS Medicare PSI 90: Patient safety and adverse events composite0.84Same 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-32Not available66
Hospital return days for heart failure patients15.5Not available222
Hospital return days for pneumonia patients11.6Not available142
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)16.2Same as national764
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)12.7Same as national659
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 surgery1Same as national47
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate13.3Same as national66
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients18.6Same as national34
Heart failure (HF) 30-Day Readmission Rate22.6Same as national222
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate16.5Same as national142

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 rating2493
Doctor communication - star rating3493
Communication about medicines - star rating2493
Discharge information - star rating2493
Cleanliness - star rating4493
Quietness - star rating3493
Overall hospital rating - star rating3493
Recommend hospital - star rating3493
Summary star rating3493

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 Hyperglycemia117943
Hospital Harm - Severe Hypoglycemia11773
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination821257
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 better190439
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 better183399
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better34240
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 seen128718
Head CT results
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients66182
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing5515
Appropriate care for severe sepsis and septic shock6073
Septic Shock 3-Hour Bundle
Septic Shock 6-Hour Bundle
Severe Sepsis 3-Hour Bundle7773
Severe Sepsis 6-Hour Bundle8547
Discharged on Antithrombotic Therapy9854
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 2
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 St Mary's General Hospital rated?
St Mary's General Hospital has a 3 out of 5 CMS overall star rating as of the latest CMS release.
Does St Mary's General Hospital have emergency services?
Yes. St Mary's General Hospital operates a 24/7 emergency department.
Where is St Mary's General Hospital located?
St Mary's General Hospital is located at 350 Boulevard, Passaic, NJ 07055.
What type of hospital is St Mary's General Hospital?
St Mary's General Hospital is classified by CMS as a Acute Care Hospitals facility (Proprietary).

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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