St Marys Hospital

Hospital in Decatur, IL, Medicare certification number 140166. CMS publishes 63 quality measures for it.

Medicare certification

Provider of Services

CCN: 140166The 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: May 14, 2021
Beds: 355
Overall star rating: 1 of 5Care Compare
Address: 1800 E Lake Shore Dr
Decatur, IL 62521
(217) 464-2966

NPI records for this facility 1

St Marys Hospital Decatur of the Hospital Sisters of the Third Order
- General Acute Care Hospital
- Decatur, IL
- NPI 1326041229
Medicare enrollment

Patient survey (HCAHPS) 9

Medicare Care Compare

Cleanliness - star rating Worse2 of 5
- State average 3.19 (computed here)
- National average 3.44 (computed here)
- Period from 10/01/2024
Communication about medicines - star rating Worse2 of 5
- State average 2.56 (computed here)
- National average 2.71 (computed here)
- Period from 10/01/2024
Discharge information - star rating Better4 of 5
- State average 3.24 (computed here)
- National average 3.31 (computed here)
- Period from 10/01/2024
Doctor communication - star rating As expected3 of 5
- State average 2.89 (computed here)
- National average 3.12 (computed here)
- Period from 10/01/2024
Nurse communication - star rating Better4 of 5
- State average 3.31 (computed here)
- National average 3.43 (computed here)
- Period from 10/01/2024
Overall hospital rating - star rating Worse3 of 5
- State average 3.14 (computed here)
- National average 3.29 (computed here)
- Period from 10/01/2024
Quietness - star rating Better4 of 5
- State average 3.24 (computed here)
- National average 3.27 (computed here)
- Period from 10/01/2024
Recommend hospital - star rating Worse3 of 5
- State average 3.46 (computed here)
- National average 3.64 (computed here)
- Period from 10/01/2024
Summary star rating Worse3 of 5
- State average 3.12 (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 expected1.22
- State average 1.05 (computed here)
- National average 1.06
- No different than the national rate
- 352 patients
- Period from 07/01/2022
CMS Medicare PSI 90: Patient safety and adverse events composite Worse1.67
- State average 0.99 (computed here)
- National average 1
- Worse than the national value
- Period from 07/01/2022
Death rate among surgical inpatients with serious treatable complications As expected177.51
- State average 172.62 (computed here)
- National average 173.3
- No different than the national rate
- 42 patients
- Period from 07/01/2022
Death rate for COPD patients As expected10
- State average 8.22 (computed here)
- National average 8.6
- No different than the national rate
- 93 patients
- Period from 07/01/2022
Death rate for heart attack patients As expected11.8
- State average 11.78 (computed here)
- National average 11.9
- No different than the national rate
- 58 patients
- Period from 07/01/2022
Death rate for heart failure patients As expected12.3
- State average 10.49 (computed here)
- National average 11.1
- No different than the national rate
- 282 patients
- Period from 07/01/2022
Death rate for pneumonia patients As expected15
- State average 15.41 (computed here)
- National average 15.2
- No different than the national rate
- 290 patients
- Period from 07/01/2022
Death rate for stroke patients As expected13
- State average 11.77 (computed here)
- National average 11.9
- No different than the national rate
- 39 patients
- Period from 07/01/2023
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate As expected4.1
- State average 4.05 (computed here)
- National average 3.9
- No different than the national rate
- 745 patients
- Period from 07/01/2024
Iatrogenic pneumothorax rate As expected0.25
- State average 0.21 (computed here)
- National average 0.21
- No different than the national rate
- 2,457 patients
- Period from 07/01/2022
In-hospital fall-associated fracture rate As expected0.25
- State average 0.27 (computed here)
- National average 0.27
- No different than the national rate
- 2,468 patients
- Period from 07/01/2022
Perioperative pulmonary embolism or deep vein thrombosis rate As expected4.14
- State average 3.71 (computed here)
- National average 3.52
- No different than the national rate
- 533 patients
- Period from 07/01/2022
Postoperative acute kidney injury requiring dialysis rate As expected2.02
- State average 1.67 (computed here)
- National average 1.67
- No different than the national rate
- 216 patients
- Period from 07/01/2022
Postoperative hemorrhage or hematoma rate As expected2.3
- State average 2.3 (computed here)
- National average 2.34
- No different than the national rate
- 502 patients
- Period from 07/01/2022
Postoperative respiratory failure rate As expected17.6
- State average 9.53 (computed here)
- National average 9.42
- No different than the national rate
- 222 patients
- Period from 07/01/2022
Postoperative sepsis rate As expected6.38
- State average 5.15 (computed here)
- National average 5.27
- No different than the national rate
- 185 patients
- Period from 07/01/2022
Postoperative wound dehiscence rate As expected1.69
- State average 1.74 (computed here)
- National average 1.77
- No different than the national rate
- 100 patients
- Period from 07/01/2022
Pressure ulcer rate Worse1.92
- State average 0.57 (computed here)
- National average 0.63
- Worse than the national rate
- 2,011 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 1

Medicare Care Compare

Clostridium Difficile (C.Diff) As expected0
- State average 0.37
- 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 — 12
SSI - Colon Surgery — 13

Outpatient imaging 2

Medicare Care Compare

Abdomen CT Use of Contrast Material 8.8
- State average 6.49 (computed here)
- National average 5.83 (computed here)
- Period from 07/01/2024
Breast Cancer Screening Recall Rates 6.6
- State average 7.81 (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) 1
- State average 1
- National average 0.99 (computed here)
- Period from 01/01/2024

Timely and effective care 21

Medicare Care Compare

Antithrombotic Therapy by End of Hospital Day 2 100
- State average 94.02 (computed here)
- National average 92.79 (computed here)
- 29 patients
- Period from 01/01/2024
Appropriate care for severe sepsis and septic shock 61
- State average 63
- National average 65
- 113 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 153
- State average 171
- National average 168
- 375 patients
- Period from 10/01/2024
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better 562
- State average 318
- National average 287
- 22 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 148
- State average 162
- National average 162
- 335 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 226
- State average 288
- National average 257
- 26 patients
- Period from 10/01/2024
Discharged on Antithrombotic Therapy 100
- State average 97 (computed here)
- National average 96.1 (computed here)
- 32 patients
- Period from 01/01/2024
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients 13
- State average 95
- National average 93
- 139 patients
- Period from 01/01/2024
Head CT results 83
- State average 75
- National average 69
- 12 patients
- Period from 10/01/2024
Healthcare workers given influenza vaccination 79
- State average 87
- National average 78
- 635 patients
- Period from 10/01/2024
Hospital Harm - Opioid Related Adverse Events 1
- State average 0.23 (computed here)
- National average 0.18 (computed here)
- 1,525 patients
- Period from 01/01/2024
Hospital Harm - Severe Hyperglycemia 13
- State average 8.66 (computed here)
- National average 8.08 (computed here)
- 3,587 patients
- Period from 01/01/2024
Hospital Harm - Severe Hypoglycemia 3
- State average 1.11 (computed here)
- National average 1.09 (computed here)
- 739 patients
- Period from 01/01/2024
Intensive Care Unit Venous Thromboembolism Prophylaxis 97
- State average 94.61 (computed here)
- National average 93.49 (computed here)
- 502 patients
- Period from 01/01/2024
Left before being seen 2
- State average 3
- National average 2
- 21,333 patients
- Period from 01/01/2024
Safe Use of Opioids - Concurrent Prescribing 13
- State average 16
- National average 15
- 553 patients
- Period from 01/01/2024
Septic Shock 3-Hour Bundle 80
- State average 72
- National average 73
- 30 patients
- Period from 10/01/2024
Septic Shock 6-Hour Bundle 100
- State average 86
- National average 87
- 19 patients
- Period from 10/01/2024
Severe Sepsis 3-Hour Bundle 71
- State average 79
- National average 81
- 113 patients
- Period from 10/01/2024
Severe Sepsis 6-Hour Bundle 92
- State average 93
- National average 93
- 52 patients
- Period from 10/01/2024
Venous Thromboembolism Prophylaxis 87
- State average 81.77 (computed here)
- National average 82.23 (computed here)
- 1,194 patients
- Period from 01/01/2024

Measures CMS does not publish for this facility (9)

Anticoagulation Therapy for Atrial Fibrillation/Flutter — 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
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 expected14.2
- State average 14.43 (computed here)
- National average 14.4
- No different than the national rate
- 50 patients
- Period from 07/01/2023
Heart failure (HF) 30-Day Readmission Rate As expected22.7
- State average 21.51 (computed here)
- National average 21.3
- No different than the national rate
- 308 patients
- Period from 07/01/2023
Hospital return days for heart attack patients -9.9
- State average 11.54 (computed here)
- National average 6.71 (computed here)
- Average days per 100 discharges
- 56 patients
- Period from 07/01/2022
Hospital return days for heart failure patients 23.2
- State average 8.22 (computed here)
- National average 4.02 (computed here)
- Average days per 100 discharges
- 318 patients
- Period from 07/01/2022
Hospital return days for pneumonia patients 64.2
- State average 13.94 (computed here)
- National average 5.65 (computed here)
- More days than average per 100 discharges
- 303 patients
- Period from 07/01/2022
Pneumonia (PN) 30-Day Readmission Rate As expected18.6
- State average 17.5 (computed here)
- National average 17.3
- No different than the national rate
- 292 patients
- Period from 07/01/2023
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy As expected5.3
- State average 5.18 (computed here)
- National average 5.4
- No different than the national rate
- 25 patients
- Period from 01/01/2024
Rate of inpatient admissions for patients receiving outpatient chemotherapy As expected10.1
- State average 11.17 (computed here)
- National average 10.7
- No different than the national rate
- 25 patients
- Period from 01/01/2024
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients As expected20.8
- State average 20.07 (computed here)
- National average 20
- No different than the national rate
- 121 patients
- Period from 07/01/2023
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies) As expected12.5
- State average 12.97 (computed here)
- National average 13
- No different than the national rate
- 759 patients
- Period from 01/01/2022
Ratio of unplanned hospital visits after hospital outpatient surgery As expected0.9
- State average 1.02 (computed here)
- National average 1.01 (computed here)
- No different than expected
- 254 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 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.