JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

St Marys Hospital

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At a glance

St Marys Hospital carries a 1-star CMS overall rating — below 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 Days584Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases0.392Not 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 Days668Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases0.366Not 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 Procedures26Not available
SSI - Colon Surgery: Predicted Cases0.737Not 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 ProceduresNot available
SSI - Abdominal Hysterectomy: Predicted CasesNot available
SSI - Abdominal Hysterectomy: Observed CasesNot available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitNot available
MRSA Bacteremia: Upper Confidence LimitNot available
MRSA Bacteremia: Patient Days9783Not available
MRSA Bacteremia: Predicted Cases0.318Not available
MRSA Bacteremia: Observed Cases1Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence LimitSame as national
Clostridium Difficile (C.Diff): Upper Confidence Limit1.161Same as national
Clostridium Difficile (C.Diff): Patient Days9783Same as national
Clostridium Difficile (C.Diff): Predicted Cases2.580Same 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 Rate4.6Same as national474
Death rate for heart attack patients12.9Same as national82
Death rate for CABG surgery patientsNot available
Death rate for COPD patients8.5Same as national83
Death rate for heart failure patients11.6Same as national324
Death rate for pneumonia patients16.1Same as national328
Death rate for stroke patients11.1Same as national75
Pressure ulcer rate1.92Worse than national2011
Death rate among surgical inpatients with serious treatable complications177.51Same as national42
Iatrogenic pneumothorax rate0.25Same as national2457
In-hospital fall-associated fracture rate0.25Same as national2468
Postoperative hemorrhage or hematoma rate2.30Same as national502
Postoperative acute kidney injury requiring dialysis rate2.02Same as national216
Postoperative respiratory failure rate17.60Same as national222
Perioperative pulmonary embolism or deep vein thrombosis rate4.14Same as national533
Postoperative sepsis rate6.38Same as national185
Postoperative wound dehiscence rate1.69Same as national100
Abdominopelvic accidental puncture or laceration rate1.22Same as national352
CMS Medicare PSI 90: Patient safety and adverse events composite1.67Worse than 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 patients26.4Not available78
Hospital return days for heart failure patients4.4Not available368
Hospital return days for pneumonia patients80.1Not available332
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)15.1Same as national729
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)12.5Same as national759
Rate of inpatient admissions for patients receiving outpatient chemotherapy10.1Same as national25
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy5.3Same as national25
Ratio of unplanned hospital visits after hospital outpatient surgery0.9Same as national254
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate13.8Same as national78
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients19.1Same as national97
Heart failure (HF) 30-Day Readmission Rate20.4Same as national368
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate18.3Same as national332

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 rating3333
Doctor communication - star rating3333
Communication about medicines - star rating2333
Discharge information - star rating3333
Cleanliness - star rating2333
Quietness - star rating3333
Overall hospital rating - star rating2333
Recommend hospital - star rating2333
Summary star rating3333

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 Hyperglycemia133587
Hospital Harm - Severe Hypoglycemia3739
Hospital Harm - Opioid Related Adverse Events11525
Healthcare workers given influenza vaccination79635
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 better162373
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 better154327
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better43034
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better66024
Left before being seen221333
Head CT results8312
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients13139
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing13553
Appropriate care for severe sepsis and septic shock5799
Septic Shock 3-Hour Bundle7128
Septic Shock 6-Hour Bundle9315
Severe Sepsis 3-Hour Bundle7099
Severe Sepsis 6-Hour Bundle9144
Discharged on Antithrombotic Therapy10032
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 210029
Venous Thromboembolism Prophylaxis871194
Intensive Care Unit Venous Thromboembolism Prophylaxis97502

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 MeasureNot Applicable (our hospital does not provide inpatient labor/delivery care)

Frequently asked questions

How is St Marys Hospital rated?
St Marys Hospital has a 1 out of 5 CMS overall star rating as of the latest CMS release.
Does St Marys Hospital have emergency services?
Yes. St Marys Hospital operates a 24/7 emergency department.
Where is St Marys Hospital located?
St Marys Hospital is located at 1800 E Lake Shore Dr, Decatur, IL 62521.
What type of hospital is St Marys Hospital?
St Marys Hospital 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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