Nacogdoches Memorial Hospital

Hospital in Nacogdoches, TX, Medicare certification number 450508. CMS publishes 47 quality measures for it.

Medicare certification

Provider of Services

CCN: 450508The 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: Proprietary
Control type: Private (for profit)
Participating since: May 6, 1968
Last certification: May 26, 2022
Beds: 231
Overall star rating: 2 of 5Care Compare
Most recent change of ownership: Mar 11, 2024 (2 total)
Address: 1204 Mound St
Nacogdoches, TX 75961
(936) 564-4611

NPI records for this facility 1

Nacogdoches County Hospital District
- Rural Acute Care Hospital
- Nacogdoches, TX
- NPI 1801831748
Medicare enrollment

Patient survey (HCAHPS) 9

Medicare Care Compare

Cleanliness - star rating Worse2 of 5
- State average 3.71 (computed here)
- National average 3.44 (computed here)
- Period from 10/01/2024
Communication about medicines - star rating Better3 of 5
- State average 2.67 (computed here)
- National average 2.71 (computed here)
- Period from 10/01/2024
Discharge information - star rating Worse3 of 5
- State average 3.07 (computed here)
- National average 3.31 (computed here)
- Period from 10/01/2024
Doctor communication - star rating Worse2 of 5
- State average 2.96 (computed here)
- National average 3.12 (computed here)
- Period from 10/01/2024
Nurse communication - star rating Worse3 of 5
- State average 3.28 (computed here)
- National average 3.43 (computed here)
- Period from 10/01/2024
Overall hospital rating - star rating Worse3 of 5
- State average 3.32 (computed here)
- National average 3.29 (computed here)
- Period from 10/01/2024
Quietness - star rating Better4 of 5
- State average 3.82 (computed here)
- National average 3.27 (computed here)
- Period from 10/01/2024
Recommend hospital - star rating Better4 of 5
- State average 3.69 (computed here)
- National average 3.64 (computed here)
- Period from 10/01/2024
Summary star rating Worse3 of 5
- State average 3.27 (computed here)
- National average 3.27 (computed here)
- Period from 10/01/2024

Complications and deaths 16

Medicare Care Compare

Abdominopelvic accidental puncture or laceration rate As expected1.02
- State average 1.03 (computed here)
- National average 1.06
- No different than the national rate
- 80 patients
- Period from 07/01/2022
CMS Medicare PSI 90: Patient safety and adverse events composite As expected0.97
- State average 0.97 (computed here)
- National average 1
- No different than the national value
- Period from 07/01/2022
Death rate for COPD patients As expected8
- State average 8.7 (computed here)
- National average 8.6
- No different than the national rate
- 40 patients
- Period from 07/01/2022
Death rate for heart failure patients As expected10.3
- State average 10.52 (computed here)
- National average 11.1
- No different than the national rate
- 74 patients
- Period from 07/01/2022
Death rate for pneumonia patients As expected15.6
- State average 14.69 (computed here)
- National average 15.2
- No different than the national rate
- 121 patients
- Period from 07/01/2022
Death rate for stroke patients As expected11.2
- State average 12.01 (computed here)
- National average 11.9
- No different than the national rate
- 37 patients
- Period from 07/01/2023
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate As expected4.6
- State average 3.89 (computed here)
- National average 3.9
- No different than the national rate
- 463 patients
- Period from 07/01/2024
Iatrogenic pneumothorax rate As expected0.26
- State average 0.21 (computed here)
- National average 0.21
- No different than the national rate
- 1,111 patients
- Period from 07/01/2022
In-hospital fall-associated fracture rate As expected0.31
- State average 0.26 (computed here)
- National average 0.27
- No different than the national rate
- 1,059 patients
- Period from 07/01/2022
Perioperative pulmonary embolism or deep vein thrombosis rate As expected4.18
- State average 3.34 (computed here)
- National average 3.52
- No different than the national rate
- 172 patients
- Period from 07/01/2022
Postoperative acute kidney injury requiring dialysis rate As expected1.67
- State average 1.62 (computed here)
- National average 1.67
- No different than the national rate
- 31 patients
- Period from 07/01/2022
Postoperative hemorrhage or hematoma rate As expected2.26
- State average 2.31 (computed here)
- National average 2.34
- No different than the national rate
- 160 patients
- Period from 07/01/2022
Postoperative respiratory failure rate As expected8.91
- State average 10.06 (computed here)
- National average 9.42
- No different than the national rate
- 31 patients
- Period from 07/01/2022
Postoperative sepsis rate As expected5.16
- State average 5.23 (computed here)
- National average 5.27
- No different than the national rate
- 26 patients
- Period from 07/01/2022
Postoperative wound dehiscence rate As expected1.74
- State average 1.77 (computed here)
- National average 1.77
- No different than the national rate
- 30 patients
- Period from 07/01/2022
Pressure ulcer rate As expected0.43
- State average 0.52 (computed here)
- National average 0.63
- No different than the national rate
- 876 patients
- Period from 07/01/2022

Measures CMS does not publish for this facility (4)

Death rate among surgical inpatients with serious treatable complications — 1
Death rate for CABG surgery patients — 5
Death rate for heart attack patients — 1
Rate of complications for hip/knee replacement patients — 1

Infections 2

Medicare Care Compare

Central Line Associated Bloodstream Infection (ICU + select Wards) As expected0
- State average 0.48
- National average 1
- No different than national benchmark
- Period from 10/01/2024
Clostridium Difficile (C.Diff) Better0.2
- State average 0.24
- National average 1
- Better than the national benchmark
- Period from 10/01/2024

Measures CMS does not publish for this facility (4)

Catheter Associated Urinary Tract Infections (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 12
- State average 7.72 (computed here)
- National average 5.83 (computed here)
- Period from 07/01/2024
Breast Cancer Screening Recall Rates 6.5
- State average 6.86 (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) 1.08
- State average 1.03
- National average 0.99 (computed here)
- Period from 01/01/2024

Timely and effective care 10

Medicare Care Compare

Appropriate care for severe sepsis and septic shock 51
- State average 68
- 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 178
- State average 150
- National average 168
- 372 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 307
- State average 260
- National average 287
- 13 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 174
- State average 145
- National average 162
- 344 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 204
- State average 233
- National average 257
- 15 patients
- Period from 10/01/2024
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients 57
- State average 92
- National average 93
- 21 patients
- Period from 01/01/2024
Left before being seen 2
- State average 1
- National average 2
- 14,819 patients
- Period from 01/01/2024
Septic Shock 3-Hour Bundle 33
- State average 74
- National average 73
- 15 patients
- Period from 10/01/2024
Severe Sepsis 3-Hour Bundle 79
- State average 83
- National average 81
- 75 patients
- Period from 10/01/2024
Severe Sepsis 6-Hour Bundle 80
- State average 93
- National average 93
- 41 patients
- Period from 10/01/2024

Measures CMS does not publish for this facility (20)

Anticoagulation Therapy for Atrial Fibrillation/Flutter — 5
Antithrombotic Therapy by End of Hospital Day 2 — 5
Discharged on Antithrombotic Therapy — 5
Emergency department volume — low
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
Healthcare workers given influenza vaccination — 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
Intensive Care Unit Venous Thromboembolism Prophylaxis — 5
Safe Use of Opioids - Concurrent Prescribing — 5
Septic Shock 6-Hour Bundle — 1, 2, 3
ST-Segment Elevation Myocardial Infarction (STEMI) — 5
Venous Thromboembolism Prophylaxis — 5

Unplanned visits 7

Medicare Care Compare

Heart failure (HF) 30-Day Readmission Rate As expected21.7
- State average 21.26 (computed here)
- National average 21.3
- No different than the national rate
- 134 patients
- Period from 07/01/2023
Hospital return days for heart failure patients 16.4
- State average -1.32 (computed here)
- National average 4.02 (computed here)
- Average days per 100 discharges
- 82 patients
- Period from 07/01/2022
Hospital return days for pneumonia patients -4.1
- State average 2.42 (computed here)
- National average 5.65 (computed here)
- Average days per 100 discharges
- 131 patients
- Period from 07/01/2022
Pneumonia (PN) 30-Day Readmission Rate As expected18.5
- State average 17.32 (computed here)
- National average 17.3
- No different than the national rate
- 195 patients
- Period from 07/01/2023
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients As expected19.3
- State average 19.85 (computed here)
- National average 20
- No different than the national rate
- 81 patients
- Period from 07/01/2023
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies) As expected13.1
- State average 13.1 (computed here)
- National average 13
- No different than the national rate
- 40 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
- 32 patients
- Period from 01/01/2024

Measures CMS does not publish for this facility (7)

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 — 5
Rate of inpatient admissions for patients receiving outpatient chemotherapy — 5
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.