Nacogdoches Medical Center

Hospital in Nacogdoches, TX, Medicare certification number 450656. CMS publishes 58 quality measures for it.

Medicare certification

Provider of Services

CCN: 450656The 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 - Other
Control type: Other
Participating since: Mar 6, 1975
Last certification: Jun 21, 2024
Beds: 150
Overall star rating: 3 of 5Care Compare
Address: 4920 NE Stallings Drive
Nacogdoches, TX 75965
(936) 569-9481

NPI records for this facility 1

TH Healthcare, LTD
- General Acute Care Hospital
- Nacogdoches, TX
- NPI 1700885076
Medicare enrollment

Patient survey (HCAHPS) 9

Medicare Care Compare

Cleanliness - star rating Worse3 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 Better4 of 5
- State average 3.07 (computed here)
- National average 3.31 (computed here)
- Period from 10/01/2024
Doctor communication - star rating Better4 of 5
- State average 2.96 (computed here)
- National average 3.12 (computed here)
- Period from 10/01/2024
Nurse communication - star rating Better4 of 5
- State average 3.28 (computed here)
- National average 3.43 (computed here)
- Period from 10/01/2024
Overall hospital rating - star rating Better4 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 Better4 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 expected0.95
- State average 1.03 (computed here)
- National average 1.06
- No different than the national rate
- 299 patients
- Period from 07/01/2022
CMS Medicare PSI 90: Patient safety and adverse events composite As expected0.94
- 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 expected180.04
- State average 166 (computed here)
- National average 173.3
- No different than the national rate
- 39 patients
- Period from 07/01/2022
Death rate for COPD patients As expected9.4
- State average 8.7 (computed here)
- National average 8.6
- No different than the national rate
- 38 patients
- Period from 07/01/2022
Death rate for heart attack patients As expected12.9
- State average 11.91 (computed here)
- National average 11.9
- No different than the national rate
- 72 patients
- Period from 07/01/2022
Death rate for heart failure patients As expected10.5
- State average 10.52 (computed here)
- National average 11.1
- No different than the national rate
- 163 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
- 351 patients
- Period from 07/01/2022
Death rate for stroke patients As expected11.4
- State average 12.01 (computed here)
- National average 11.9
- No different than the national rate
- 112 patients
- Period from 07/01/2023
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate As expected3.6
- State average 3.89 (computed here)
- National average 3.9
- No different than the national rate
- 1,409 patients
- Period from 07/01/2024
Iatrogenic pneumothorax rate As expected0.18
- State average 0.21 (computed here)
- National average 0.21
- No different than the national rate
- 2,478 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
- 2,529 patients
- Period from 07/01/2022
Perioperative pulmonary embolism or deep vein thrombosis rate As expected4.78
- State average 3.34 (computed here)
- National average 3.52
- No different than the national rate
- 546 patients
- Period from 07/01/2022
Postoperative hemorrhage or hematoma rate As expected2.32
- State average 2.31 (computed here)
- National average 2.34
- No different than the national rate
- 557 patients
- Period from 07/01/2022
Postoperative wound dehiscence rate As expected2.36
- State average 1.77 (computed here)
- National average 1.77
- No different than the national rate
- 120 patients
- Period from 07/01/2022
Pressure ulcer rate As expected0.25
- State average 0.52 (computed here)
- National average 0.63
- No different than the national rate
- 2,046 patients
- Period from 07/01/2022
Rate of complications for hip/knee replacement patients As expected5
- State average 4.14 (computed here)
- National average 4.1
- No different than the national rate
- 69 patients
- Period from 04/01/2023

Measures CMS does not publish for this facility (4)

Death rate for CABG surgery patients — 5
Postoperative acute kidney injury requiring dialysis rate — 7
Postoperative respiratory failure rate — 7
Postoperative sepsis rate — 7

Infections 4

Medicare Care Compare

Catheter Associated Urinary Tract Infections (ICU + select Wards) As expected0.23
- State average 0.35
- National average 1
- No different than national benchmark
- Period from 10/01/2024
Central Line Associated Bloodstream Infection (ICU + select Wards) As expected0.69
- State average 0.48
- National average 1
- No different than national benchmark
- Period from 10/01/2024
Clostridium Difficile (C.Diff) Better0.25
- State average 0.24
- National average 1
- Better than the national benchmark
- Period from 10/01/2024
SSI - Colon Surgery As expected1.48
- State average 0.73
- National average 1
- No different than national benchmark
- Period from 10/01/2024

Measures CMS does not publish for this facility (2)

MRSA Bacteremia — 13
SSI - Abdominal Hysterectomy — 13

Outpatient imaging 2

Medicare Care Compare

Abdomen CT Use of Contrast Material 2.8
- State average 7.72 (computed here)
- National average 5.83 (computed here)
- Period from 07/01/2024
Breast Cancer Screening Recall Rates 6.7
- 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) 0.99
- State average 1.03
- National average 0.99 (computed here)
- Period from 01/01/2024

Timely and effective care 16

Medicare Care Compare

Appropriate care for severe sepsis and septic shock 61
- State average 68
- National average 65
- 90 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 162
- State average 150
- National average 168
- 471 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 384
- State average 260
- National average 287
- 24 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 156
- State average 145
- National average 162
- 440 patients
- Period from 10/01/2024
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients 88
- State average 92
- National average 93
- 81 patients
- Period from 01/01/2024
Head CT results 63
- State average 67
- National average 69
- 19 patients
- Period from 10/01/2024
Healthcare workers given influenza vaccination 71
- State average 74
- National average 78
- 1,099 patients
- Period from 10/01/2024
Hospital Harm - Severe Hyperglycemia 9
- State average 6.38 (computed here)
- National average 8.08 (computed here)
- 7,645 patients
- Period from 01/01/2024
Hospital Harm - Severe Hypoglycemia 1
- State average 1.19 (computed here)
- National average 1.09 (computed here)
- 1,240 patients
- Period from 01/01/2024
Left before being seen 2
- State average 1
- National average 2
- 32,998 patients
- Period from 01/01/2024
Safe Use of Opioids - Concurrent Prescribing 18
- State average 14
- National average 15
- 1,201 patients
- Period from 01/01/2024
Septic Shock 3-Hour Bundle 58
- State average 74
- National average 73
- 31 patients
- Period from 10/01/2024
Septic Shock 6-Hour Bundle 92
- State average 89
- National average 87
- 13 patients
- Period from 10/01/2024
Severe Sepsis 3-Hour Bundle 84
- State average 83
- National average 81
- 90 patients
- Period from 10/01/2024
Severe Sepsis 6-Hour Bundle 93
- State average 93
- National average 93
- 57 patients
- Period from 10/01/2024
Venous Thromboembolism Prophylaxis 80
- State average 78.56 (computed here)
- National average 82.23 (computed here)
- 2,669 patients
- Period from 01/01/2024

Measures CMS does not publish for this facility (14)

Anticoagulation Therapy for Atrial Fibrillation/Flutter — 5
Antithrombotic Therapy by End of Hospital Day 2 — 5
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
Discharged on Antithrombotic Therapy — 5
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
Hospital Harm - Opioid Related Adverse Events — 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

Unplanned visits 10

Medicare Care Compare

Acute Myocardial Infarction (AMI) 30-Day Readmission Rate As expected15.2
- State average 14.48 (computed here)
- National average 14.4
- No different than the national rate
- 104 patients
- Period from 07/01/2023
Heart failure (HF) 30-Day Readmission Rate As expected23.6
- State average 21.26 (computed here)
- National average 21.3
- No different than the national rate
- 253 patients
- Period from 07/01/2023
Hospital return days for heart attack patients 52.8
- State average 11.3 (computed here)
- National average 6.71 (computed here)
- More days than average per 100 discharges
- 69 patients
- Period from 07/01/2022
Hospital return days for heart failure patients 2.6
- State average -1.32 (computed here)
- National average 4.02 (computed here)
- Average days per 100 discharges
- 174 patients
- Period from 07/01/2022
Hospital return days for pneumonia patients 18.1
- State average 2.42 (computed here)
- National average 5.65 (computed here)
- Average days per 100 discharges
- 366 patients
- Period from 07/01/2022
Pneumonia (PN) 30-Day Readmission Rate Worse20.4
- State average 17.32 (computed here)
- National average 17.3
- Worse than the national rate
- 533 patients
- Period from 07/01/2023
Rate of readmission after hip/knee replacement As expected4.9
- State average 5.89 (computed here)
- National average 5.8
- No different than the national rate
- 77 patients
- Period from 07/01/2023
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients As expected21.3
- State average 19.85 (computed here)
- National average 20
- No different than the national rate
- 88 patients
- Period from 07/01/2023
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies) As expected12.7
- State average 13.1 (computed here)
- National average 13
- No different than the national rate
- 56 patients
- Period from 01/01/2022
Ratio of unplanned hospital visits after hospital outpatient surgery As expected1.2
- State average 1.02 (computed here)
- National average 1.01 (computed here)
- No different than expected
- 113 patients
- Period from 01/01/2024

Measures CMS does not publish for this facility (4)

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 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.