★★★☆☆3 out of 5 StarsWhy 3 stars?Mercy Regional Medical Center (Acute Care)'s 3-star rating reflects roughly average performance across all CMS quality domains.
CMS Overall Hospital Quality Star Rating · Mercy Regional Medical Center (Acute Care)
How was Mercy Regional Medical Center (Acute Care)'s 3-star rating calculated?
The CMS Overall Hospital Quality Star Rating applies to
acute care hospitals like Mercy Regional Medical Center (Acute Care). CMS standardizes
every underlying measure against the national rate, computes
a weighted score for each of five domains, sums them by the
fixed weights below, and assigns 1–5 stars using k-means
clustering across all reporting hospitals.
Domains that fed Mercy Regional Medical Center (Acute Care)'s rating
Domain
Weight
Measures reported
Hospital performance vs. national
Mortality
22%
5 of 7
0 better5 same0 worse
Safety of Care
22%
9 of 19
0 better9 same0 worse
Readmissions
22%
3 of 6
0 better3 same0 worse
Timely & Effective Care
12%
16 of 22
5 better7 same4 worse
Patient Experience
22%
HCAHPS
See HCAHPS detail below
How star meaning varies by hospital type.
This CMS Overall Star Rating only applies to acute care
hospitals. Children's hospitals (Pediatric Quality), psychiatric
hospitals (IPFQR), inpatient rehabilitation facilities (IRF QRP),
long-term acute care hospitals (LTACH QRP), and VA medical centers
each use separate quality programs designed for their patient
populations. Comparing star ratings across these facility types
isn't meaningful — see the methodology page for the full mapping
of which program applies to which facility.
How this emergency department performs on the measures that
matter most when you need care fast.
138 minTypical ER visit before heading homeNear the national median of 148 min
3%Walked out before being seenWorse than ~75% of hospitals · national median 1%
69%Recommended sepsis care givenNear the national median of 64%
From CMS Timely & Effective Care reporting.
Quality measures
Mortality
Same as National Average
Measures the rate at which patients die within 30 days of hospital admission for specific conditions. A lower mortality rate indicates better outcomes.
Mercy Regional Medical Center
WorseUS AvgBetter
Underlying measures:Hybrid Hospital-Wide All-Cause Risk Standardized Mortality RateNo Different Than the National RateHospital score: 4.70 95% interval: 3.60 – 6.20 Sample size: 242Reporting period: 07/01/2023 – 06/30/2024CMS measure id: Hybrid_HWMDeath rate for COPD patientsNo Different Than the National RateHospital score: 9.40 95% interval: 5.50 – 15.50 Sample size: 30Reporting period: 07/01/2021 – 06/30/2024CMS measure id: MORT_30_COPDDeath rate for heart failure patientsNo Different Than the National RateHospital score: 14.30 95% interval: 9.30 – 21.30 Sample size: 41Reporting period: 07/01/2021 – 06/30/2024CMS measure id: MORT_30_HFDeath rate for pneumonia patientsNo Different Than the National RateHospital score: 18.80 95% interval: 14.20 – 24.60 Sample size: 199Reporting period: 07/01/2021 – 06/30/2024CMS measure id: MORT_30_PNDeath rate for stroke patientsNo Different Than the National RateHospital score: 14.60 95% interval: 9.60 – 22.20 Sample size: 33Reporting period: 07/01/2021 – 06/30/2024CMS measure id: MORT_30_STKDeath rate for CABG surgery patientsNot AvailableHospital score: — Reporting period: 07/01/2021 – 06/30/2024CMS measure id: MORT_30_CABGDeath rate for heart attack patientsNumber of Cases Too SmallHospital score: — Reporting period: 07/01/2021 – 06/30/2024CMS measure id: MORT_30_AMI
Safety of Care
Same as National Average
Tracks hospital-acquired infections, surgical complications, and other patient safety indicators. Lower rates indicate better safety practices.
Mercy Regional Medical Center
WorseUS AvgBetter
Underlying measures:Abdominopelvic accidental puncture or laceration rateNo Different Than the National RateHospital score: 1.04 95% interval: 0.00 – 2.13 Sample size: 86Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_15Clostridium Difficile (C.Diff)No Different than National BenchmarkHospital score: 0.00 SIR Reporting period: 07/01/2024 – 06/30/2025CMS measure id: HAI_6_SIRIatrogenic pneumothorax rateNo Different Than the National RateHospital score: 0.20 95% interval: 0.00 – 0.43 Sample size: 1,022Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_06In-hospital fall-associated fracture rateNo Different Than the National RateHospital score: 0.26 95% interval: 0.05 – 0.48 Sample size: 1,020Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_08Postoperative hemorrhage or hematoma rateNo Different Than the National RateHospital score: 2.29 95% interval: 0.57 – 4.01 Sample size: 65Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_09Perioperative pulmonary embolism or deep vein thrombosis rateNo Different Than the National RateHospital score: 3.43 95% interval: 0.81 – 6.04 Sample size: 72Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_12Pressure ulcer rateNo Different Than the National RateHospital score: 0.51 95% interval: 0.00 – 1.73 Sample size: 663Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_03CMS Medicare PSI 90: Patient safety and adverse events compositeNo Different Than the National ValueHospital score: 0.95 95% interval: 0.46 – 1.44 Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_90Postoperative wound dehiscence rateNo Different Than the National RateHospital score: 1.76 95% interval: 0.23 – 3.29 Sample size: 26Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_14Catheter Associated Urinary Tract Infections (ICU + select Wards)Not AvailableHospital score: — SIR Reporting period: 07/01/2024 – 06/30/2025CMS measure id: HAI_2_SIRCentral Line Associated Bloodstream Infection (ICU + select Wards)Not AvailableHospital score: — SIR Reporting period: 07/01/2024 – 06/30/2025CMS measure id: HAI_1_SIRRate of complications for hip/knee replacement patientsNot AvailableHospital score: — Reporting period: 04/01/2021 – 03/31/2024CMS measure id: COMP_HIP_KNEEMRSA BacteremiaNot AvailableHospital score: — SIR Reporting period: 07/01/2024 – 06/30/2025CMS measure id: HAI_5_SIRPostoperative acute kidney injury requiring dialysis rateNot AvailableHospital score: — Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_10Postoperative respiratory failure rateNumber of Cases Too SmallHospital score: — Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_11Postoperative sepsis rateNot AvailableHospital score: — Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_13SSI - Abdominal HysterectomyNot AvailableHospital score: — SIR Reporting period: 07/01/2024 – 06/30/2025CMS measure id: HAI_4_SIRSSI - Colon SurgeryNot AvailableHospital score: — SIR Reporting period: 07/01/2024 – 06/30/2025CMS measure id: HAI_3_SIRDeath rate among surgical inpatients with serious treatable complicationsNot AvailableHospital score: — Reporting period: 07/01/2022 – 06/30/2024CMS measure id: PSI_04
Readmissions
Same as National Average
Measures how often patients return to the hospital within 30 days of discharge. Lower readmission rates suggest effective treatment and discharge planning.
Based on the HCAHPS survey — patient satisfaction with communication, cleanliness, pain management, and discharge information.
WorseUS AvgBetter
Patient survey detail — the questions feeding the Patient Experience domain above
expand ↓
CMS computes the Patient Experience domain from the federal HCAHPS survey.
Each bar below is one survey question; the percentage is the share of
Mercy's recent patients who gave the most positive
response. HCAHPS percentages aren't directly comparable across all measures —
see the methodology page for how CMS weights them.
Communication with Nurses83%
Communication with Doctors92%
Hospital Cleanliness70%
Hospital Quietness59%
Staff ResponsivenessN/A
Discharge Information89%
Overall Hospital Rating (9 or 10)73%
Would Recommend Hospital79%
Percentages represent patients who gave the most positive response. Survey conducted by CMS through the HCAHPS program.
Timely & Effective Care
Same as National Average
Measures how quickly the hospital provides important treatments such as antibiotics for pneumonia or interventions for heart attacks.
Mercy Regional Medical Center
WorseUS AvgBetter
Underlying measures:Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patientsBetter than ~75% of hospitalsHospital score: 100.00 % National median: 97.00 % (higher is better)
Sample size: 48Reporting period: 01/01/2024 – 12/31/2024CMS measure id: OP_29Intensive Care Unit Venous Thromboembolism ProphylaxisBetter than ~75% of hospitalsHospital score: 100.00 % National median: 97.00 % (higher is better)
Sample size: 212Reporting period: 01/01/2024 – 12/31/2024CMS measure id: VTE_2Septic Shock 3-Hour BundleBetter than ~75% of hospitalsHospital score: 83.00 % National median: 72.00 % (higher is better)
Sample size: 29Reporting period: 07/01/2024 – 06/30/2025CMS measure id: SEP_SH_3HRSevere Sepsis 6-Hour BundleBetter than ~75% of hospitalsHospital score: 98.00 % National median: 94.00 % (higher is better)
Sample size: 44Reporting period: 07/01/2024 – 06/30/2025CMS measure id: SEV_SEP_6HRVenous Thromboembolism ProphylaxisBetter than ~75% of hospitalsHospital score: 97.00 % National median: 90.00 % (higher is better)
Sample size: 532Reporting period: 01/01/2024 – 12/31/2024CMS measure id: VTE_1Discharged on Antithrombotic TherapyNear the national medianHospital score: 97.00 % National median: 98.00 % (higher is better)
Sample size: 31Reporting period: 01/01/2024 – 12/31/2024CMS measure id: STK_02Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is betterNear the national medianHospital score: 279.00 min National median: 248.00 min (lower is better)
Sample size: 24Reporting period: 07/01/2024 – 06/30/2025CMS measure id: OP_18cAverage (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 betterNear the national medianHospital score: 138.00 min National median: 148.00 min (lower is better)
Sample size: 356Reporting period: 07/01/2024 – 06/30/2025CMS measure id: OP_18bAverage (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is betterNear the national medianHospital score: 283.00 min National median: 294.00 min (lower is better)
Sample size: 40Reporting period: 07/01/2024 – 06/30/2025CMS measure id: OP_18dAverage (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 betterNear the national medianHospital score: 153.00 min National median: 154.00 min (lower is better)
Sample size: 420Reporting period: 07/01/2024 – 06/30/2025CMS measure id: OP_18aAppropriate care for severe sepsis and septic shockNear the national medianHospital score: 69.00 % National median: 64.00 % (higher is better)
Sample size: 78Reporting period: 07/01/2024 – 06/30/2025CMS measure id: SEP_1Severe Sepsis 3-Hour BundleNear the national medianHospital score: 82.00 % National median: 81.00 % (higher is better)
Sample size: 78Reporting period: 07/01/2024 – 06/30/2025CMS measure id: SEV_SEP_3HRSafe Use of Opioids - Concurrent PrescribingWorse than ~75% of hospitalsHospital score: 31.00 % National median: 15.00 % (lower is better)
Sample size: 278Reporting period: 01/01/2024 – 12/31/2024CMS measure id: SAFE_USE_OF_OPIOIDSLeft before being seenWorse than ~75% of hospitalsHospital score: 3.00 % National median: 1.00 % (lower is better)
Sample size: 10,350Reporting period: 01/01/2024 – 12/31/2024CMS measure id: OP_22Septic Shock 6-Hour BundleWorse than ~75% of hospitalsHospital score: 79.00 % National median: 89.00 % (higher is better)
Sample size: 19Reporting period: 07/01/2024 – 06/30/2025CMS measure id: SEP_SH_6HRHealthcare workers given influenza vaccinationWorse than ~75% of hospitalsHospital score: 62.00 % National median: 79.00 % (higher is better)
Sample size: 511Reporting period: 10/01/2024 – 03/31/2025CMS measure id: IMM_3
Psychiatric Unit Quality (IPFQR)
Mercy Regional Medical Center (Acute Care) operates a Medicare-certified inpatient psychiatric unit that reports under the federal IPFQR program. The measures are specific to that unit — not the hospital as a whole. They cover restraint and seclusion use, screening for medication side effects, substance-use and tobacco treatment, transitions of care, follow-up after discharge, and readmissions.
Show the psychiatric unit's 11 reported measures expand ↓
Physical Restraint Use 0.0 hours per 1,000 patient-hours
National median: 0.1 hours Near national median
HBIPS-2 — hours of physical restraint use per 1,000 patient-hours. Lower is better; restraints carry physical and psychological risks.
Seclusion Use 0.0 hours per 1,000 patient-hours
National median: 0.0 hours Near national median
HBIPS-3 — hours of seclusion per 1,000 patient-hours. Lower is better; seclusion is used only when no other intervention works.
Metabolic Screening (SMD) 94.0 %
National median: 92.0 % Near national median
SMD — % of patients on antipsychotics screened for metabolic side effects (BMI, blood glucose, cholesterol). Antipsychotics raise metabolic-syndrome risk; screening catches it early.
Substance-Use Treatment Provided 77.0 %
National median: 74.0 % Near national median
SUB-2 — % of patients with alcohol/drug use referred for treatment during admission.
Substance-Use Treatment at Discharge 69.0 %
National median: 77.0 % Worse than national median
SUB-3 — % of patients with substance-use disorder offered or referred to treatment at discharge.
Tobacco-Use Treatment at Discharge 61.0 %
National median: 64.0 % Near national median
TOB-3 — % of patients using tobacco who received counseling and/or medication at discharge.
Transition Record Completed 61.0 %
National median: 77.0 % Worse than national median
TR-1 — % of discharges with a completed transition record including medications, follow-up plan, and crisis instructions.
Follow-up Within 7 Days 27.1 %
National median: 35.4 % Worse than national median
FAPH-7 — % of patients with a follow-up outpatient mental-health visit within 7 days of discharge. Predicts lower readmission risk.
Follow-up Within 30 Days 60.4 %
National median: 60.7 % Near national median
FAPH-30 — % of patients with a follow-up outpatient mental-health visit within 30 days of discharge.
30-Day Readmission Rate 22.9 %
National median: 19.1 % Worse than national median
READM-30-IPF — risk-standardized 30-day readmission rate. No Different Than the National Rate
Influenza Immunization 71.0 %
National median: 87.0 % Worse than national median
IMM-2 — % of patients given a flu vaccine during the inpatient stay.
Mercy Regional Medical Center (Acute Care) has 110 CMS-affiliated
clinicians on its roster — physicians, advanced practice providers, and other
Medicare-enrolled professionals who list this hospital as an affiliated facility.
Top specialties
Nurse Practitioner17
Family Practice12
Internal Medicine12
Diagnostic Radiology11
Physician Assistant6
Obstetrics/Gynecology5
Orthopedic Surgery5
Emergency Medicine5
Self-reported primary specialty in the CMS Doctors & Clinicians dataset. Many clinicians serve multiple facilities.
Practice characteristics
Accept Medicare assignment
106(96%)
Bill Medicare directly at the approved rate — patients only owe co-insurance/deductible.
Offer telehealth
9(8%)
Indicated by the clinician in their CMS profile as routinely providing virtual visits.
Medicare quality scoring (MIPS)
39 of these clinicians have a published
Merit-based Incentive Payment System (MIPS) final score.
Of those, 14
(36%) score above the national median of 85.5.
MIPS scoring is heavily compressed at the top of the 0–100 range, so individual scores
are not a reliable consumer signal. We surface roster-level coverage and the share
above the national median instead.
Source: CMS Doctors and Clinicians (Care Compare) national downloadable file
and MIPS Performance Year final scores, as of 2026-07-18.
Affiliations from the CMS Facility Affiliations dataset. About 16% of small
facilities (critical access, rural emergency, freestanding psych, IRF/LTCH)
do not appear in the affiliations file and therefore have no panel.
Find a Doctor
Search the 110 clinicians affiliated with Mercy Regional Medical Center (Acute Care).
Each name links to that clinician's official Medicare Care Compare profile, where you can see
their credentials, secondary specialties, group affiliations, and (when applicable) MIPS quality scores.
No clinicians match that search. Try a broader term like "internal medicine" or just a last name.
Roster from CMS Doctors and Clinicians (Care Compare), updated 2026-07-18.
A clinician may also practice at other facilities; "affiliated" means this hospital is on their CMS
profile, not that they exclusively work here.
Procedure volumes are Medicare fee-for-service counts from the CMS
clinician utilization file (all practice locations, not just this
hospital). Industry payment totals are from CMS Open Payments,
program year 2024, and include meals, travel, consulting, and
speaking fees; payments are legal and common — we show them for
transparency, not as a quality judgment.
Pricing & Costs
This hospital participates in price transparency under the federal
Hospital Price Transparency Rule. View 822 published procedures
— gross charges, cash prices, and per-payer negotiated rates where available.
How Mercy Regional Medical Center (Acute Care) compares nearby
Compared with the 8 other acute-care hospitals within 50 miles
— 9 facilities in all, CMS data only.
Among the 9 acute-care hospitals within 50 miles, Mercy Regional Medical Center (Acute Care)'s overall star rating is 3★; the median among the 7 peers reporting it is 3★.
Measure
This facility
Nearby median
Best nearby
Overall star rating
reported by 7 of 8 nearby peers
3★
3★
4★
Patient experience (HCAHPS) star
reported by 5 of 8 nearby peers
Cohort: within 50 miles · CMS data period 2026-06 · method cohort-v1
· comparisons are never affected by claiming or payment.
How nearby comparisons work
Quality and ratings data are sourced from the U.S. Centers for
Medicare & Medicaid Services (CMS) Hospital Compare program.
Star ratings are CMS's own calculation; CareRanks does not modify
or re-weight them. Facility-level details (address, beds,
ownership, teaching status) come from CMS provider files and the
CMS Provider of Services file.
Pricing data, where shown, is drawn from the hospital's own
Machine-Readable File (MRF) published under the federal Hospital
Price Transparency Rule. See our methodology for the full update
cadence and limitations.