St Nicholas Hospital

Hospital in Sheboygan, WI, Medicare certification number 520044. CMS publishes 51 quality measures for it.

Medicare certification

Provider of Services

CCN: 520044The 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: Jan 30, 2012
Beds: 185
Overall star rating: 3 of 5Care Compare
Address: 3100 Superior Ave
Sheboygan, WI 53081
(920) 459-8300

NPI records for this facility 2

St Nicholas Hospital-Sisters of the Third Order of St. Francis
- End-Stage Renal Disease (ESRD) Treatment Clinic/Center
- Sheboygan, WI
- NPI 1427009992
Medicare enrollment
St. Nicholas Hospital-Sisters of the Third Order of St Francis
- General Acute Care Hospital
- Sheboygan, WI
- NPI 1730184342
Medicare enrollment

Patient survey (HCAHPS) 9

Medicare Care Compare

Cleanliness - star rating Worse3 of 5
- State average 4.01 (computed here)
- National average 3.44 (computed here)
- Period from 10/01/2024
Communication about medicines - star rating Better3 of 5
- State average 3.58 (computed here)
- National average 2.71 (computed here)
- Period from 10/01/2024
Discharge information - star rating Better4 of 5
- State average 4.14 (computed here)
- National average 3.31 (computed here)
- Period from 10/01/2024
Doctor communication - star rating Better4 of 5
- State average 3.68 (computed here)
- National average 3.12 (computed here)
- Period from 10/01/2024
Nurse communication - star rating Better4 of 5
- State average 4.22 (computed here)
- National average 3.43 (computed here)
- Period from 10/01/2024
Overall hospital rating - star rating Better4 of 5
- State average 3.88 (computed here)
- National average 3.29 (computed here)
- Period from 10/01/2024
Quietness - star rating Better4 of 5
- State average 3.95 (computed here)
- National average 3.27 (computed here)
- Period from 10/01/2024
Recommend hospital - star rating Better4 of 5
- State average 4.14 (computed here)
- National average 3.64 (computed here)
- Period from 10/01/2024
Summary star rating Better4 of 5
- State average 4.04 (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 expected1.3
- State average 1.12 (computed here)
- National average 1.06
- No different than the national rate
- 128 patients
- Period from 07/01/2022
CMS Medicare PSI 90: Patient safety and adverse events composite As expected0.93
- State average 1.02 (computed here)
- National average 1
- No different than the national value
- Period from 07/01/2022
Death rate for heart failure patients As expected11.5
- State average 12.02 (computed here)
- National average 11.1
- No different than the national rate
- 39 patients
- Period from 07/01/2022
Death rate for pneumonia patients As expected17.3
- State average 15.15 (computed here)
- National average 15.2
- No different than the national rate
- 69 patients
- Period from 07/01/2022
Death rate for stroke patients As expected11.8
- State average 11.76 (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 expected3.7
- State average 3.88 (computed here)
- National average 3.9
- No different than the national rate
- 452 patients
- Period from 07/01/2024
Iatrogenic pneumothorax rate As expected0.21
- State average 0.21 (computed here)
- National average 0.21
- No different than the national rate
- 658 patients
- Period from 07/01/2022
In-hospital fall-associated fracture rate As expected0.31
- State average 0.27 (computed here)
- National average 0.27
- No different than the national rate
- 646 patients
- Period from 07/01/2022
Perioperative pulmonary embolism or deep vein thrombosis rate As expected3.26
- State average 3.5 (computed here)
- National average 3.52
- No different than the national rate
- 129 patients
- Period from 07/01/2022
Postoperative hemorrhage or hematoma rate As expected2.61
- State average 2.45 (computed here)
- National average 2.34
- No different than the national rate
- 122 patients
- Period from 07/01/2022
Postoperative wound dehiscence rate As expected1.75
- State average 1.81 (computed here)
- National average 1.77
- No different than the national rate
- 36 patients
- Period from 07/01/2022
Pressure ulcer rate As expected0.51
- State average 0.76 (computed here)
- National average 0.63
- No different than the national rate
- 500 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 COPD patients — 1
Death rate for heart attack patients — 1
Postoperative acute kidney injury requiring dialysis rate — 1
Postoperative respiratory failure rate — 1
Postoperative sepsis rate — 1
Rate of complications for hip/knee replacement patients — 1

Infections 1

Medicare Care Compare

Clostridium Difficile (C.Diff) As expected0.42
- State average 0.53
- 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 3.3
- State average 4.55 (computed here)
- National average 5.83 (computed here)
- Period from 07/01/2024
Breast Cancer Screening Recall Rates 5.3
- State average 5.62 (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) 0.87
- State average 0.9
- National average 0.99 (computed here)
- Period from 01/01/2024

Timely and effective care 19

Medicare Care Compare

Appropriate care for severe sepsis and septic shock 69
- State average 72
- National average 65
- 124 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 126
- State average 144
- National average 168
- 377 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 303
- State average 294
- National average 287
- 19 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 122
- State average 137
- National average 162
- 338 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 211
- State average 203
- National average 257
- 21 patients
- Period from 10/01/2024
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients 83
- State average 97
- National average 93
- 72 patients
- Period from 01/01/2024
Head CT results 64
- State average 74
- National average 69
- 14 patients
- Period from 10/01/2024
Healthcare workers given influenza vaccination 84
- State average 85
- National average 78
- 813 patients
- Period from 10/01/2024
Hospital Harm - Opioid Related Adverse Events 0
- State average 0.14 (computed here)
- National average 0.18 (computed here)
- 714 patients
- Period from 01/01/2024
Hospital Harm - Severe Hyperglycemia 15
- State average 9.13 (computed here)
- National average 8.08 (computed here)
- 1,324 patients
- Period from 01/01/2024
Hospital Harm - Severe Hypoglycemia 1
- State average 0.76 (computed here)
- National average 1.09 (computed here)
- 310 patients
- Period from 01/01/2024
Intensive Care Unit Venous Thromboembolism Prophylaxis 97
- State average 95.78 (computed here)
- National average 93.49 (computed here)
- 404 patients
- Period from 01/01/2024
Left before being seen 0
- State average 2
- National average 2
- 13,331 patients
- Period from 01/01/2024
Safe Use of Opioids - Concurrent Prescribing 16
- State average 14
- National average 15
- 279 patients
- Period from 01/01/2024
Septic Shock 3-Hour Bundle 82
- State average 77
- National average 73
- 44 patients
- Period from 10/01/2024
Septic Shock 6-Hour Bundle 94
- State average 88
- National average 87
- 31 patients
- Period from 10/01/2024
Severe Sepsis 3-Hour Bundle 81
- State average 85
- National average 81
- 125 patients
- Period from 10/01/2024
Severe Sepsis 6-Hour Bundle 94
- State average 94
- National average 93
- 72 patients
- Period from 10/01/2024
Venous Thromboembolism Prophylaxis 97
- State average 88.48 (computed here)
- National average 82.23 (computed here)
- 436 patients
- Period from 01/01/2024

Measures CMS does not publish for this facility (11)

Anticoagulation Therapy for Atrial Fibrillation/Flutter — 1
Antithrombotic Therapy by End of Hospital Day 2 — 1
Discharged on Antithrombotic Therapy — 1
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
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery — 5
ST-Segment Elevation Myocardial Infarction (STEMI) — 1

Unplanned visits 7

Medicare Care Compare

Heart failure (HF) 30-Day Readmission Rate As expected21.3
- State average 21.16 (computed here)
- National average 21.3
- No different than the national rate
- 70 patients
- Period from 07/01/2023
Hospital return days for heart failure patients -3.5
- State average -5.03 (computed here)
- National average 4.02 (computed here)
- Average days per 100 discharges
- 37 patients
- Period from 07/01/2022
Hospital return days for pneumonia patients 17.9
- State average -3.39 (computed here)
- National average 5.65 (computed here)
- Average days per 100 discharges
- 72 patients
- Period from 07/01/2022
Pneumonia (PN) 30-Day Readmission Rate As expected19.1
- State average 17.04 (computed here)
- National average 17.3
- No different than the national rate
- 132 patients
- Period from 07/01/2023
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients As expected18.8
- State average 19.79 (computed here)
- National average 20
- No different than the national rate
- 63 patients
- Period from 07/01/2023
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies) As expected14
- State average 13.21 (computed here)
- National average 13
- No different than the national rate
- 861 patients
- Period from 01/01/2022
Ratio of unplanned hospital visits after hospital outpatient surgery As expected0.9
- State average 1.03 (computed here)
- National average 1.01 (computed here)
- No different than expected
- 187 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 — 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

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.