Ascension St Vincent'S Clay County

Hospital in Middleburg, FL, Medicare certification number 100321. CMS publishes 57 quality measures for it.

Medicare certification

Provider of Services

CCN: 100321The 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: Nov 18, 2013
Last certification: Feb 10, 2015
Beds: 134
Overall star rating: 3 of 5Care Compare
Address: 1670 St Vincents Way
Middleburg, FL 32068
(904) 602-1000

NPI records for this facility 1

St. Vincent'S Medical Center-Clay County, Inc.
- General Acute Care Hospital
- Middleburg, FL
- NPI 1457690471
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 Worse1 of 5
- State average 2.13 (computed here)
- National average 2.71 (computed here)
- Period from 10/01/2024
Discharge information - star rating Worse3 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 Better4 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 18

Medicare Care Compare

Abdominopelvic accidental puncture or laceration rate As expected0.92
- State average 1.02 (computed here)
- National average 1.06
- No different than the national rate
- 494 patients
- Period from 07/01/2022
CMS Medicare PSI 90: Patient safety and adverse events composite As expected0.92
- 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 expected148.16
- State average 157.4 (computed here)
- National average 173.3
- No different than the national rate
- 38 patients
- Period from 07/01/2022
Death rate for COPD patients As expected10.6
- State average 8.44 (computed here)
- National average 8.6
- No different than the national rate
- 89 patients
- Period from 07/01/2022
Death rate for heart attack patients As expected11.6
- State average 11.73 (computed here)
- National average 11.9
- No different than the national rate
- 121 patients
- Period from 07/01/2022
Death rate for heart failure patients As expected11.4
- State average 10.18 (computed here)
- National average 11.1
- No different than the national rate
- 238 patients
- Period from 07/01/2022
Death rate for pneumonia patients As expected13.7
- State average 14.53 (computed here)
- National average 15.2
- No different than the national rate
- 337 patients
- Period from 07/01/2022
Death rate for stroke patients As expected17.2
- State average 12.29 (computed here)
- National average 11.9
- No different than the national rate
- 92 patients
- Period from 07/01/2023
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate As expected3.9
- State average 3.85 (computed here)
- National average 3.9
- No different than the national rate
- 1,379 patients
- Period from 07/01/2024
Iatrogenic pneumothorax rate As expected0.3
- State average 0.2 (computed here)
- National average 0.21
- No different than the national rate
- 2,859 patients
- Period from 07/01/2022
In-hospital fall-associated fracture rate As expected0.24
- State average 0.26 (computed here)
- National average 0.27
- No different than the national rate
- 3,049 patients
- Period from 07/01/2022
Perioperative pulmonary embolism or deep vein thrombosis rate As expected3.35
- State average 3.45 (computed here)
- National average 3.52
- No different than the national rate
- 402 patients
- Period from 07/01/2022
Postoperative acute kidney injury requiring dialysis rate As expected1.62
- State average 1.67 (computed here)
- National average 1.67
- No different than the national rate
- 113 patients
- Period from 07/01/2022
Postoperative hemorrhage or hematoma rate As expected2.41
- State average 2.22 (computed here)
- National average 2.34
- No different than the national rate
- 396 patients
- Period from 07/01/2022
Postoperative respiratory failure rate As expected11.06
- State average 10.09 (computed here)
- National average 9.42
- No different than the national rate
- 119 patients
- Period from 07/01/2022
Postoperative sepsis rate As expected4.8
- State average 5.31 (computed here)
- National average 5.27
- No different than the national rate
- 81 patients
- Period from 07/01/2022
Postoperative wound dehiscence rate As expected2
- State average 1.74 (computed here)
- National average 1.77
- No different than the national rate
- 116 patients
- Period from 07/01/2022
Pressure ulcer rate As expected0.26
- State average 0.49 (computed here)
- National average 0.63
- No different than the national rate
- 2,272 patients
- Period from 07/01/2022

Measures CMS does not publish for this facility (2)

Death rate for CABG surgery patients — 5
Rate of complications for hip/knee replacement patients — 1

Infections 5

Medicare Care Compare

Catheter Associated Urinary Tract Infections (ICU + select Wards) As expected0
- 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 expected0
- State average 0.43
- National average 1
- No different than national benchmark
- Period from 10/01/2024
Clostridium Difficile (C.Diff) Better0.31
- State average 0.21
- National average 1
- Better than the national benchmark
- Period from 10/01/2024
MRSA Bacteremia As expected0
- State average 0.69
- National average 1
- No different than national benchmark
- Period from 10/01/2024
SSI - Colon Surgery As expected0
- 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 2

Medicare Care Compare

Abdomen CT Use of Contrast Material 8.9
- State average 4.69 (computed here)
- National average 5.83 (computed here)
- Period from 07/01/2024
Breast Cancer Screening Recall Rates 6.2
- State average 13.95 (computed here)
- National average 8.08 (computed here)
- Period from 07/01/2024

Spending per patient 1

Medicare Care Compare

Medicare hospital spending per patient (Medicare Spending per Beneficiary) 0.89
- State average 1.02
- National average 0.99 (computed here)
- Period from 01/01/2024

Timely and effective care 13

Medicare Care Compare

Appropriate care for severe sepsis and septic shock 77
- State average 73
- National average 65
- 140 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 188
- State average 159
- National average 168
- 388 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 188
- State average 156
- National average 162
- 378 patients
- Period from 10/01/2024
Discharged on Antithrombotic Therapy 100
- State average 96.49 (computed here)
- National average 96.1 (computed here)
- 32 patients
- Period from 01/01/2024
Head CT results 55
- State average 73
- National average 69
- 11 patients
- Period from 10/01/2024
Healthcare workers given influenza vaccination 94
- State average 58
- National average 78
- 1,832 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)
- 223 patients
- Period from 01/01/2024
Safe Use of Opioids - Concurrent Prescribing 16
- State average 16
- National average 15
- 417 patients
- Period from 01/01/2024
Septic Shock 3-Hour Bundle 77
- State average 78
- National average 73
- 44 patients
- Period from 10/01/2024
Septic Shock 6-Hour Bundle 96
- State average 92
- National average 87
- 25 patients
- Period from 10/01/2024
Severe Sepsis 3-Hour Bundle 87
- State average 85
- National average 81
- 140 patients
- Period from 10/01/2024
Severe Sepsis 6-Hour Bundle 97
- State average 95
- National average 93
- 71 patients
- Period from 10/01/2024
Venous Thromboembolism Prophylaxis 94
- State average 90.41 (computed here)
- National average 82.23 (computed here)
- 877 patients
- Period from 01/01/2024

Measures CMS does not publish for this facility (17)

Anticoagulation Therapy for Atrial Fibrillation/Flutter — 5
Antithrombotic Therapy by End of Hospital Day 2 — 5
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better — 1
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better — 1
Emergency department volume — 5
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
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
Left before being seen — 5
ST-Segment Elevation Myocardial Infarction (STEMI) — 1, 29

Unplanned visits 9

Medicare Care Compare

Acute Myocardial Infarction (AMI) 30-Day Readmission Rate As expected13.5
- State average 14.67 (computed here)
- National average 14.4
- No different than the national rate
- 120 patients
- Period from 07/01/2023
Heart failure (HF) 30-Day Readmission Rate As expected23.8
- State average 21.72 (computed here)
- National average 21.3
- No different than the national rate
- 315 patients
- Period from 07/01/2023
Hospital return days for heart attack patients -21
- State average 6.58 (computed here)
- National average 6.71 (computed here)
- Average days per 100 discharges
- 112 patients
- Period from 07/01/2022
Hospital return days for heart failure patients 10.3
- State average 5.09 (computed here)
- National average 4.02 (computed here)
- Average days per 100 discharges
- 275 patients
- Period from 07/01/2022
Hospital return days for pneumonia patients -14.3
- State average 10 (computed here)
- National average 5.65 (computed here)
- Average days per 100 discharges
- 369 patients
- Period from 07/01/2022
Pneumonia (PN) 30-Day Readmission Rate As expected16.7
- State average 17.53 (computed here)
- National average 17.3
- No different than the national rate
- 393 patients
- Period from 07/01/2023
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients As expected20.9
- State average 20.09 (computed here)
- National average 20
- No different than the national rate
- 132 patients
- Period from 07/01/2023
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies) As expected15.8
- State average 12.99 (computed here)
- National average 13
- No different than the national rate
- 478 patients
- Period from 01/01/2022
Ratio of unplanned hospital visits after hospital outpatient surgery As expected1
- State average 1.02 (computed here)
- National average 1.01 (computed here)
- No different than expected
- 119 patients
- Period from 01/01/2024

Measures CMS does not publish for this facility (5)

Hybrid Hospital-Wide All-Cause Readmission Measure (HWR) — 4
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy — 1, 29
Rate of inpatient admissions for patients receiving outpatient chemotherapy — 1, 29
Rate of readmission after hip/knee replacement — 1
Rate of readmission for CABG — 5

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.