Uf Health Leesburg Hospital

Hospital in Leesburg, FL, Medicare certification number 100084. CMS publishes 63 quality measures for it.

Medicare certification

Provider of Services

CCN: 100084The number CMS certifies the facility under, not a provider identifier
Status: Active
Provider type: Hospital – Short-term
Listed by Care Compare as: Acute Care Hospitals
Ownership: Voluntary non-profit - Private
Control type: Private (not for profit)
Participating since: Jul 1, 1966
Last certification: Sep 15, 2023
Beds: 330
Overall star rating: 3 of 5Care Compare
Address: 600 E Dixie Ave
Leesburg, FL 34748
(352) 323-5762

NPI records for this facility 3

Leesburg Regional Medical Center Inc
- Urgent Care Clinic/Center
- Leesburg, FL
- NPI 1245001189
Medicare enrollment
Leesburg Regional Medical Center Inc
- General Acute Care Hospital
- Leesburg, FL
- NPI 1245226190
Medicare enrollment
LRMC Urgent Care Center
- Urgent Care Clinic/Center
- Leesburg, FL
- NPI 1598841389
Medicare enrollment

Patient survey (HCAHPS) 9

Medicare Care Compare

Cleanliness - star rating Better4 of 5
- State average 3.35 (computed here)
- National average 3.44 (computed here)
- Period from 10/01/2024
Communication about medicines - star rating Better3 of 5
- State average 2.13 (computed here)
- National average 2.71 (computed here)
- Period from 10/01/2024
Discharge information - star rating Better4 of 5
- State average 2.56 (computed here)
- National average 3.31 (computed here)
- Period from 10/01/2024
Doctor communication - star rating Worse2 of 5
- State average 2.41 (computed here)
- National average 3.12 (computed here)
- Period from 10/01/2024
Nurse communication - star rating Worse3 of 5
- State average 2.75 (computed here)
- National average 3.43 (computed here)
- Period from 10/01/2024
Overall hospital rating - star rating Worse3 of 5
- State average 2.84 (computed here)
- National average 3.29 (computed here)
- Period from 10/01/2024
Quietness - star rating Worse3 of 5
- State average 2.95 (computed here)
- National average 3.27 (computed here)
- Period from 10/01/2024
Recommend hospital - star rating Worse3 of 5
- State average 3.25 (computed here)
- National average 3.64 (computed here)
- Period from 10/01/2024
Summary star rating Worse3 of 5
- State average 2.69 (computed here)
- National average 3.27 (computed here)
- Period from 10/01/2024

Complications and deaths 20

Medicare Care Compare

Abdominopelvic accidental puncture or laceration rate As expected1.25
- State average 1.02 (computed here)
- National average 1.06
- No different than the national rate
- 1,219 patients
- Period from 07/01/2022
CMS Medicare PSI 90: Patient safety and adverse events composite As expected0.84
- State average 0.97 (computed here)
- National average 1
- No different than the national value
- Period from 07/01/2022
Death rate among surgical inpatients with serious treatable complications As expected165.8
- State average 157.4 (computed here)
- National average 173.3
- No different than the national rate
- 78 patients
- Period from 07/01/2022
Death rate for CABG surgery patients As expected2.9
- State average 2.43 (computed here)
- National average 2.4
- No different than the national rate
- 296 patients
- Period from 07/01/2022
Death rate for COPD patients As expected8.3
- State average 8.44 (computed here)
- National average 8.6
- No different than the national rate
- 210 patients
- Period from 07/01/2022
Death rate for heart attack patients As expected13.2
- State average 11.73 (computed here)
- National average 11.9
- No different than the national rate
- 348 patients
- Period from 07/01/2022
Death rate for heart failure patients As expected8.8
- State average 10.18 (computed here)
- National average 11.1
- No different than the national rate
- 721 patients
- Period from 07/01/2022
Death rate for pneumonia patients As expected13.4
- State average 14.53 (computed here)
- National average 15.2
- No different than the national rate
- 505 patients
- Period from 07/01/2022
Death rate for stroke patients As expected12.2
- State average 12.29 (computed here)
- National average 11.9
- No different than the national rate
- 273 patients
- Period from 07/01/2023
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate As expected3.6
- State average 3.85 (computed here)
- National average 3.9
- No different than the national rate
- 5,220 patients
- Period from 07/01/2024
Iatrogenic pneumothorax rate As expected0.22
- State average 0.2 (computed here)
- National average 0.21
- No different than the national rate
- 8,270 patients
- Period from 07/01/2022
In-hospital fall-associated fracture rate As expected0.3
- State average 0.26 (computed here)
- National average 0.27
- No different than the national rate
- 8,608 patients
- Period from 07/01/2022
Perioperative pulmonary embolism or deep vein thrombosis rate As expected4.08
- State average 3.45 (computed here)
- National average 3.52
- No different than the national rate
- 2,147 patients
- Period from 07/01/2022
Postoperative acute kidney injury requiring dialysis rate As expected2.08
- State average 1.67 (computed here)
- National average 1.67
- No different than the national rate
- 738 patients
- Period from 07/01/2022
Postoperative hemorrhage or hematoma rate As expected2.36
- State average 2.22 (computed here)
- National average 2.34
- No different than the national rate
- 1,901 patients
- Period from 07/01/2022
Postoperative respiratory failure rate As expected6.48
- State average 10.09 (computed here)
- National average 9.42
- No different than the national rate
- 790 patients
- Period from 07/01/2022
Postoperative sepsis rate As expected5.41
- State average 5.31 (computed here)
- National average 5.27
- No different than the national rate
- 717 patients
- Period from 07/01/2022
Postoperative wound dehiscence rate As expected1.59
- State average 1.74 (computed here)
- National average 1.77
- No different than the national rate
- 315 patients
- Period from 07/01/2022
Pressure ulcer rate As expected0.13
- State average 0.49 (computed here)
- National average 0.63
- No different than the national rate
- 7,451 patients
- Period from 07/01/2022
Rate of complications for hip/knee replacement patients As expected3.5
- State average 4.08 (computed here)
- National average 4.1
- No different than the national rate
- 61 patients
- Period from 04/01/2023

Infections 5

Medicare Care Compare

Catheter Associated Urinary Tract Infections (ICU + select Wards) As expected0.54
- State average 0.27
- National average 1
- No different than national benchmark
- Period from 10/01/2024
Central Line Associated Bloodstream Infection (ICU + select Wards) As expected1.28
- State average 0.43
- National average 1
- No different than national benchmark
- Period from 10/01/2024
Clostridium Difficile (C.Diff) Better0.32
- State average 0.21
- National average 1
- Better than the national benchmark
- Period from 10/01/2024
MRSA Bacteremia As expected0.6
- State average 0.69
- National average 1
- No different than national benchmark
- Period from 10/01/2024
SSI - Colon Surgery As expected0.95
- State average 0.61
- National average 1
- No different than national benchmark
- Period from 10/01/2024

Measures CMS does not publish for this facility (1)

SSI - Abdominal Hysterectomy — 13

Outpatient imaging 1

Medicare Care Compare

Abdomen CT Use of Contrast Material 0.9
- State average 4.69 (computed here)
- National average 5.83 (computed here)
- Period from 07/01/2024

Measures CMS does not publish for this facility (1)

Breast Cancer Screening Recall Rates — 1

Spending per patient 1

Medicare Care Compare

Medicare hospital spending per patient (Medicare Spending per Beneficiary) 1.04
- State average 1.02
- National average 0.99 (computed here)
- Period from 01/01/2024

Timely and effective care 16

Medicare Care Compare

Antithrombotic Therapy by End of Hospital Day 2 94
- State average 92.03 (computed here)
- National average 92.79 (computed here)
- 156 patients
- Period from 01/01/2024
Appropriate care for severe sepsis and septic shock 71
- State average 73
- National average 65
- 159 patients
- Period from 10/01/2024
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 better 173
- State average 159
- National average 168
- 417 patients
- Period from 10/01/2024
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 better 166
- State average 156
- National average 162
- 388 patients
- Period from 10/01/2024
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better 237
- State average 220
- National average 257
- 20 patients
- Period from 10/01/2024
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients 100
- State average 86
- National average 93
- 18 patients
- Period from 01/01/2024
Head CT results 83
- State average 73
- National average 69
- 23 patients
- Period from 10/01/2024
Healthcare workers given influenza vaccination 74
- State average 58
- National average 78
- 2,782 patients
- Period from 10/01/2024
Intensive Care Unit Venous Thromboembolism Prophylaxis 100
- State average 97.2 (computed here)
- National average 93.49 (computed here)
- 1,828 patients
- Period from 01/01/2024
Left before being seen 1
- State average 1
- National average 2
- 46,609 patients
- Period from 01/01/2024
Safe Use of Opioids - Concurrent Prescribing 15
- State average 16
- National average 15
- 2,799 patients
- Period from 01/01/2024
Septic Shock 3-Hour Bundle 87
- State average 78
- National average 73
- 54 patients
- Period from 10/01/2024
Septic Shock 6-Hour Bundle 87
- State average 92
- National average 87
- 38 patients
- Period from 10/01/2024
Severe Sepsis 3-Hour Bundle 83
- State average 85
- National average 81
- 159 patients
- Period from 10/01/2024
Severe Sepsis 6-Hour Bundle 92
- State average 95
- National average 93
- 88 patients
- Period from 10/01/2024
Venous Thromboembolism Prophylaxis 97
- State average 90.41 (computed here)
- National average 82.23 (computed here)
- 8,430 patients
- Period from 01/01/2024

Measures CMS does not publish for this facility (14)

Anticoagulation Therapy for Atrial Fibrillation/Flutter — 5
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better — 1
Discharged on Antithrombotic Therapy — 5
Emergency department volume — high
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
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
ST-Segment Elevation Myocardial Infarction (STEMI) — 1

Unplanned visits 11

Medicare Care Compare

Acute Myocardial Infarction (AMI) 30-Day Readmission Rate As expected15.4
- State average 14.67 (computed here)
- National average 14.4
- No different than the national rate
- 604 patients
- Period from 07/01/2023
Heart failure (HF) 30-Day Readmission Rate As expected19.1
- State average 21.72 (computed here)
- National average 21.3
- No different than the national rate
- 1,244 patients
- Period from 07/01/2023
Hospital return days for heart attack patients -15.9
- State average 6.58 (computed here)
- National average 6.71 (computed here)
- Average days per 100 discharges
- 377 patients
- Period from 07/01/2022
Hospital return days for heart failure patients 4.1
- State average 5.09 (computed here)
- National average 4.02 (computed here)
- Average days per 100 discharges
- 838 patients
- Period from 07/01/2022
Hospital return days for pneumonia patients -7.1
- State average 10 (computed here)
- National average 5.65 (computed here)
- Average days per 100 discharges
- 520 patients
- Period from 07/01/2022
Pneumonia (PN) 30-Day Readmission Rate As expected16
- State average 17.53 (computed here)
- National average 17.3
- No different than the national rate
- 775 patients
- Period from 07/01/2023
Rate of readmission after hip/knee replacement As expected6
- State average 6.04 (computed here)
- National average 5.8
- No different than the national rate
- 62 patients
- Period from 07/01/2023
Rate of readmission for CABG As expected10
- State average 11.26 (computed here)
- National average 11
- No different than the national rate
- 334 patients
- Period from 07/01/2023
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients As expected18.9
- State average 20.09 (computed here)
- National average 20
- No different than the national rate
- 386 patients
- Period from 07/01/2023
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies) As expected12.5
- State average 12.99 (computed here)
- National average 13
- No different than the national rate
- 415 patients
- Period from 01/01/2022
Ratio of unplanned hospital visits after hospital outpatient surgery Better0.7
- State average 1.02 (computed here)
- National average 1.01 (computed here)
- Better than expected
- 699 patients
- Period from 01/01/2024

Measures CMS does not publish for this facility (3)

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

Sources for this page

Provider of Services: the certification, provider type, beds and status.
Medicare Care Compare: the star rating and every measure on this page, with the state and national rates CMS publishes beside them.
NPPES NPI Registry: the NPI records connected to this certification.

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.