NPIMap

Mt San Rafael Hospital

Hospital in Trinidad, CO, Medicare certification number 061321. CMS publishes 18 quality measures for it.

Medicare certification

Provider of Services
CCN
061321The number CMS certifies the facility under, not a provider identifier
Status
Active
Provider type
Hospital – Critical access hospital
Listed by Care Compare as
Critical Access Hospitals
Ownership
Voluntary non-profit - Private
Control type
Private (not for profit)
Participating since
Jan 1, 2004
Last certification
May 12, 2022
Beds
25
Overall star rating
5 of 5Care Compare
Address
410 Benedicta Ave
Trinidad, CO 81082
(719) 846-9213

NPI records for this facility 1

Patient survey (HCAHPS) 0

Medicare Care Compare
Measures CMS does not publish for this facility (9)
  • Cleanliness - star rating — 15
  • Communication about medicines - star rating — 15
  • Discharge information - star rating — 15
  • Doctor communication - star rating — 15
  • Nurse communication - star rating — 15
  • Overall hospital rating - star rating — 15
  • Quietness - star rating — 15
  • Recommend hospital - star rating — 15
  • Summary star rating — 15

Complications and deaths 3

Medicare Care Compare
Measures CMS does not publish for this facility (17)
  • Abdominopelvic accidental puncture or laceration rate — 13
  • CMS Medicare PSI 90: Patient safety and adverse events composite — 13
  • Death rate among surgical inpatients with serious treatable complications — 13
  • Death rate for CABG surgery patients — 5
  • Death rate for heart attack patients — 1
  • Death rate for heart failure patients — 1
  • Death rate for stroke patients — 1
  • Iatrogenic pneumothorax rate — 13
  • In-hospital fall-associated fracture rate — 13
  • Perioperative pulmonary embolism or deep vein thrombosis rate — 13
  • Postoperative acute kidney injury requiring dialysis rate — 13
  • Postoperative hemorrhage or hematoma rate — 13
  • Postoperative respiratory failure rate — 13
  • Postoperative sepsis rate — 13
  • Postoperative wound dehiscence rate — 13
  • Pressure ulcer rate — 13
  • Rate of complications for hip/knee replacement patients — 5

Infections 0

Medicare Care Compare
Measures CMS does not publish for this facility (6)
  • Catheter Associated Urinary Tract Infections (ICU + select Wards) — 13
  • Central Line Associated Bloodstream Infection (ICU + select Wards) — 13
  • Clostridium Difficile (C.Diff) — 13
  • MRSA Bacteremia — 13
  • SSI - Abdominal Hysterectomy — 12
  • SSI - Colon Surgery — 13

Outpatient imaging 2

Medicare Care Compare

Spending per patient 0

Medicare Care Compare
Measures CMS does not publish for this facility (1)
  • Medicare hospital spending per patient (Medicare Spending per Beneficiary) — 5

Timely and effective care 10

Medicare Care Compare
Measures CMS does not publish for this facility (20)
  • Anticoagulation Therapy for Atrial Fibrillation/Flutter — 5
  • Antithrombotic Therapy by End of Hospital Day 2 — 1
  • Discharged on Antithrombotic Therapy — 1
  • Emergency department volume — low
  • Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients — 5
  • Global Malnutrition Composite Score — 5
  • Global Malnutrition Composite Score: Malnutrition Diagnosis Documented — 5
  • Global Malnutrition Composite Score: Malnutrition Risk Screening — 5
  • Global Malnutrition Composite Score: Nutrition Assessment — 5
  • Global Malnutrition Composite Score: Nutritional Care Plan — 5
  • Head CT results — 1
  • Hospital Harm - Opioid Related Adverse Events — 5
  • Hospital Harm - Severe Hyperglycemia — 5
  • Hospital Harm - Severe Hypoglycemia — 5
  • Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery — 5
  • Intensive Care Unit Venous Thromboembolism Prophylaxis — 5
  • Septic Shock 3-Hour Bundle — 5
  • Septic Shock 6-Hour Bundle — 5
  • ST-Segment Elevation Myocardial Infarction (STEMI) — 5
  • Venous Thromboembolism Prophylaxis — 5

Unplanned visits 3

Medicare Care Compare
Measures CMS does not publish for this facility (11)
  • Acute Myocardial Infarction (AMI) 30-Day Readmission Rate — 1
  • Heart failure (HF) 30-Day Readmission Rate — 1
  • Hospital return days for heart attack patients — 1
  • Hospital return days for heart failure patients — 1
  • Hybrid Hospital-Wide All-Cause Readmission Measure (HWR) — 4
  • Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy — 1
  • Rate of inpatient admissions for patients receiving outpatient chemotherapy — 1
  • Rate of readmission after hip/knee replacement — 5
  • Rate of readmission for CABG — 5
  • Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies) — 5
  • Ratio of unplanned hospital visits after hospital outpatient surgery — 5

Sources for this page

Better and worse are CMS's own comparison with the national rate, not ours: for most measures a low score is the good one (deaths, infections) and for others a high one is, so measures where CMS states no comparison are left uncoloured. The exception is star ratings, which are read against the national average here. Quality measures are published by CMS and are not adjusted or re-scored here. Averages marked “computed here” are the mean of every facility reporting that measure, worked out by NPIMap because CMS publishes no comparison for it. Confirm anything you rely on at Medicare Care Compare.