Ty Cobb Regional Medical Center, LLC

Hospital in Lavonia, GA, Medicare certification number 110027. CMS publishes 44 quality measures for it.

Medicare certification

Provider of Services

CCN: 110027The 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: Oct 7, 2022
Beds: 56
Overall star rating: 3 of 5Care Compare
Most recent change of ownership: Jun 1, 2015 (2 total)
Address: 367 Clear Creek Parkway
Lavonia, GA 30553
(706) 356-7800

NPI records for this facility 1

St. Mary'S Sacred Heart Hospital, Inc.
- Rural Acute Care Hospital
- Lavonia, GA
- NPI 1518354778
Medicare enrollment

Patient survey (HCAHPS) 9

Medicare Care Compare

Cleanliness - star rating Better5 of 5
- State average 3.3 (computed here)
- National average 3.44 (computed here)
- Period from 10/01/2024
Communication about medicines - star rating Better4 of 5
- State average 2.46 (computed here)
- National average 2.71 (computed here)
- Period from 10/01/2024
Discharge information - star rating Better4 of 5
- State average 2.94 (computed here)
- National average 3.31 (computed here)
- Period from 10/01/2024
Doctor communication - star rating As expected3 of 5
- State average 3.08 (computed here)
- National average 3.12 (computed here)
- Period from 10/01/2024
Nurse communication - star rating Better4 of 5
- State average 3.2 (computed here)
- National average 3.43 (computed here)
- Period from 10/01/2024
Overall hospital rating - star rating Better4 of 5
- State average 3.27 (computed here)
- National average 3.29 (computed here)
- Period from 10/01/2024
Quietness - star rating Better5 of 5
- State average 3.77 (computed here)
- National average 3.27 (computed here)
- Period from 10/01/2024
Recommend hospital - star rating Worse3 of 5
- State average 3.6 (computed here)
- National average 3.64 (computed here)
- Period from 10/01/2024
Summary star rating Better4 of 5
- State average 3.15 (computed here)
- National average 3.27 (computed here)
- Period from 10/01/2024

Complications and deaths 12

Medicare Care Compare

Abdominopelvic accidental puncture or laceration rate As expected1.05
- State average 1.07 (computed here)
- National average 1.06
- No different than the national rate
- 31 patients
- Period from 07/01/2022
CMS Medicare PSI 90: Patient safety and adverse events composite As expected0.95
- State average 1.07 (computed here)
- National average 1
- No different than the national value
- Period from 07/01/2022
Death rate for COPD patients As expected7.8
- State average 8.69 (computed here)
- National average 8.6
- No different than the national rate
- 53 patients
- Period from 07/01/2022
Death rate for heart failure patients As expected11.6
- State average 10.84 (computed here)
- National average 11.1
- No different than the national rate
- 54 patients
- Period from 07/01/2022
Death rate for pneumonia patients As expected13.4
- State average 15.21 (computed here)
- National average 15.2
- No different than the national rate
- 137 patients
- Period from 07/01/2022
Death rate for stroke patients As expected11.5
- State average 12.45 (computed here)
- National average 11.9
- No different than the national rate
- 43 patients
- Period from 07/01/2023
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate As expected4.1
- State average 4.08 (computed here)
- National average 3.9
- No different than the national rate
- 484 patients
- Period from 07/01/2024
Iatrogenic pneumothorax rate As expected0.21
- State average 0.22 (computed here)
- National average 0.21
- No different than the national rate
- 828 patients
- Period from 07/01/2022
In-hospital fall-associated fracture rate As expected0.31
- State average 0.28 (computed here)
- National average 0.27
- No different than the national rate
- 803 patients
- Period from 07/01/2022
Perioperative pulmonary embolism or deep vein thrombosis rate As expected3.41
- State average 3.81 (computed here)
- National average 3.52
- No different than the national rate
- 48 patients
- Period from 07/01/2022
Postoperative hemorrhage or hematoma rate As expected2.33
- State average 2.36 (computed here)
- National average 2.34
- No different than the national rate
- 41 patients
- Period from 07/01/2022
Pressure ulcer rate As expected0.53
- State average 0.68 (computed here)
- National average 0.63
- No different than the national rate
- 613 patients
- Period from 07/01/2022

Measures CMS does not publish for this facility (8)

Death rate among surgical inpatients with serious treatable complications — 1
Death rate for CABG surgery patients — 5
Death rate for heart attack patients — 1
Postoperative acute kidney injury requiring dialysis rate — 1
Postoperative respiratory failure rate — 1
Postoperative sepsis rate — 1
Postoperative wound dehiscence rate — 1
Rate of complications for hip/knee replacement patients — 1

Infections 1

Medicare Care Compare

Clostridium Difficile (C.Diff) As expected0
- State average 0.26
- National average 1
- No different than national benchmark
- Period from 10/01/2024

Measures CMS does not publish for this facility (5)

Catheter Associated Urinary Tract Infections (ICU + select Wards) — 13
Central Line Associated Bloodstream Infection (ICU + select Wards) — 13
MRSA Bacteremia — 13
SSI - Abdominal Hysterectomy — 13
SSI - Colon Surgery — 13

Outpatient imaging 2

Medicare Care Compare

Abdomen CT Use of Contrast Material 5.1
- State average 5.62 (computed here)
- National average 5.83 (computed here)
- Period from 07/01/2024
Breast Cancer Screening Recall Rates 5.9
- State average 6.41 (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) 0.95
- State average 0.97
- National average 0.99 (computed here)
- Period from 01/01/2024

Timely and effective care 13

Medicare Care Compare

Antithrombotic Therapy by End of Hospital Day 2 97
- State average 92.46 (computed here)
- National average 92.79 (computed here)
- 36 patients
- Period from 01/01/2024
Appropriate care for severe sepsis and septic shock 85
- State average 63
- National average 65
- 75 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 106
- State average 169
- National average 168
- 407 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 104
- State average 162
- National average 162
- 398 patients
- Period from 10/01/2024
Discharged on Antithrombotic Therapy 100
- State average 96.72 (computed here)
- National average 96.1 (computed here)
- 40 patients
- Period from 01/01/2024
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients 90
- State average 89
- National average 93
- 67 patients
- Period from 01/01/2024
Healthcare workers given influenza vaccination 40
- State average 76
- National average 78
- 493 patients
- Period from 10/01/2024
Left before being seen 1
- State average 2
- National average 2
- 24,311 patients
- Period from 01/01/2024
Safe Use of Opioids - Concurrent Prescribing 18
- State average 15
- National average 15
- 482 patients
- Period from 01/01/2024
Septic Shock 3-Hour Bundle 94
- State average 73
- National average 73
- 35 patients
- Period from 10/01/2024
Septic Shock 6-Hour Bundle 83
- State average 84
- National average 87
- 24 patients
- Period from 10/01/2024
Severe Sepsis 3-Hour Bundle 93
- State average 80
- National average 81
- 75 patients
- Period from 10/01/2024
Severe Sepsis 6-Hour Bundle 100
- State average 92
- National average 93
- 48 patients
- Period from 10/01/2024

Measures CMS does not publish for this facility (17)

Anticoagulation Therapy for Atrial Fibrillation/Flutter — 1
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better — 7
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 — medium
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
ST-Segment Elevation Myocardial Infarction (STEMI) — 1
Venous Thromboembolism Prophylaxis — 5

Unplanned visits 6

Medicare Care Compare

Heart failure (HF) 30-Day Readmission Rate As expected19.8
- State average 21.19 (computed here)
- National average 21.3
- No different than the national rate
- 124 patients
- Period from 07/01/2023
Hospital return days for heart failure patients 27.4
- State average 12.52 (computed here)
- National average 4.02 (computed here)
- Average days per 100 discharges
- 64 patients
- Period from 07/01/2022
Hospital return days for pneumonia patients -10.1
- State average 12.69 (computed here)
- National average 5.65 (computed here)
- Average days per 100 discharges
- 140 patients
- Period from 07/01/2022
Pneumonia (PN) 30-Day Readmission Rate As expected16.9
- State average 17.41 (computed here)
- National average 17.3
- No different than the national rate
- 199 patients
- Period from 07/01/2023
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients As expected19.3
- State average 19.84 (computed here)
- National average 20
- No different than the national rate
- 91 patients
- Period from 07/01/2023
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies) As expected12.3
- State average 12.97 (computed here)
- National average 13
- No different than the national rate
- 233 patients
- Period from 01/01/2022

Measures CMS does not publish for this facility (8)

Acute Myocardial Infarction (AMI) 30-Day Readmission Rate — 1
Hospital return days for heart attack 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 — 1
Rate of readmission for CABG — 5
Ratio of unplanned hospital visits after hospital outpatient surgery — 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.