Bottom quartile Middle Top quartile Percentile badges compare this hospital to all 5,426 hospitals nationally.

Overview

Address
2351 'G' RD, GRAND JUNCTION, CO 81505
Phone
(970) 644-3011
Hospital Type
Acute Care
Ownership
Non-Profit
Emergency Services
Yes
Birthing Friendly
Yes
4 /5
CMS Overall Rating
p63
Acute Care — General medical and surgical hospital participating in Medicare IPPS. Subject to CMS quality reporting and payment adjustment programs (VBP, HRRP, HAC).

CMS Star Rating — Quality Domain Breakdown

CMS computes the overall star rating from five quality domains. Each domain compares this hospital's measures against national benchmarks.

Mortality 3 of 7 measures reported
3
Better No different Worse
30-day death rates for heart attack, heart failure, pneumonia, COPD, stroke, CABG, and kidney disease.
Safety of Care 4 of 8 measures reported
4
Better No different Worse
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 8 of 11 measures reported
1
6
1
Better No different Worse
30-day unplanned readmission rates for heart attack, heart failure, pneumonia, COPD, hip/knee replacement, and CABG.
Patient Experience 8 of 8 measures reported
8 measures reported (comparative data not available for this domain)
HCAHPS survey scores — patient-reported experience with communication, responsiveness, cleanliness, and discharge planning.
Timely & Effective Care 10 of 12 measures reported
10 measures reported (comparative data not available for this domain)
Process-of-care measures including flu immunization, blood clot prevention, and appropriate use of imaging.

Readmissions — Hospital Readmissions Reduction Program

The Excess Readmission Ratio (ERR) compares this hospital's 30-day readmission rate to expected, adjusting for patient mix. An ERR of 1.0 means readmissions are as expected; > 1.0 triggers a Medicare payment penalty (up to 3%).

This hospital does not have excess readmissions triggering HRRP penalties.
Acute Myocardial Infarction (Heart Attack)
— Not reported
Heart Failure
0.9644 p27
Pneumonia
0.9685 p31
COPD
— Not reported
Hip/Knee Replacement
0.8816 p19
CABG Surgery
— Not reported
Expected (1.0) National median

Value-Based Purchasing

The Hospital VBP Program adjusts Medicare payments based on clinical quality. The Total Performance Score (TPS) is a weighted composite of four domains, each worth 25%. This hospital's TPS is below the national median, suggesting a negative payment adjustment.

27.6 p43
Total Performance Score
National median: 29.5
Clinical Outcomes 25% weight
0.0 p0
Nat'l median: 5.0
Measures mortality rates for conditions like heart attack, heart failure, pneumonia, and COPD. Based on 30-day risk-standardized mortality.
Safety 25% weight
3.3 p5
Nat'l median: 10.0
Patient safety measures including healthcare-associated infections (CLABSI, CAUTI, SSI, MRSA, C. diff) and perioperative complications.
Person & Community Engagement 25% weight
16.8 p89
Nat'l median: 8.8
Based on HCAHPS patient experience survey results — communication with nurses and doctors, hospital cleanliness, pain management, discharge information.
Efficiency & Cost Reduction 25% weight
7.5 p67
Nat'l median: 2.5
Based on Medicare Spending Per Beneficiary (MSPB). Measures episode-of-care costs from 3 days before admission through 30 days after discharge.

CMS Payment Programs

Three Medicare programs adjust hospital payments based on quality performance. Hospitals can be penalized under multiple programs simultaneously.

Readmissions (HRRP)
Not Penalized
Worst ERR: 0.9685
Value-Based Purchasing
27.6 TPS
Below national median
HAC Reduction
Payment Reduced
HAC Score: 0.6343

Complications & Deaths

30-day mortality rates, patient safety indicators, and complication rates. "Better" means statistically significantly better than the national rate.

Measure Score vs. National Denominator
COMP_HIP_KNEE 3.90 No Different Than the National Rate 52
Hybrid_HWM 4.40 No Different Than the National Rate 359
MORT_30_AMI Number of Cases Too Small
MORT_30_CABG
MORT_30_COPD 10.40 No Different Than the National Rate 26
MORT_30_HF 10.70 No Different Than the National Rate 51
MORT_30_PN 17.40 No Different Than the National Rate 88
MORT_30_STK Number of Cases Too Small
PSI_03 0.45 No Different Than the National Rate 757
PSI_04 Number of Cases Too Small
PSI_06 0.26 No Different Than the National Rate 1,163
PSI_08 0.26 No Different Than the National Rate 1,167
PSI_09 2.36 No Different Than the National Rate 531
PSI_10 2.00 No Different Than the National Rate 382
PSI_11 10.53 No Different Than the National Rate 365
PSI_12 4.04 No Different Than the National Rate 545
PSI_13 6.04 No Different Than the National Rate 339
PSI_14 1.72 No Different Than the National Rate 104
PSI_15 1.49 No Different Than the National Rate 355
PSI_90 1.06 No Different Than the National Value

Patient Experience (HCAHPS)

Hospital Consumer Assessment of Healthcare Providers and Systems — standardized patient survey measuring satisfaction with care.

Measure Score Star Rating
H_COMP_1_A_P: Nurses "always" communicated well 81%
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 3%
H_COMP_1_U_P: Nurses "usually" communicated well 16%
H_COMP_1_LINEAR_SCORE: Nurse communication - linear mean score
H_COMP_1_STAR_RATING: Nurse communication - star rating 4
H_NURSE_RESPECT_A_P: Nurses "always" treated them with courtesy and respect 88%
H_NURSE_RESPECT_SN_P: Nurses "sometimes" or "never" treated them with courtesy and respect 2%
H_NURSE_RESPECT_U_P: Nurses "usually" treated them with courtesy and respect 10%
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 77%
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 4%
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 19%
H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand 77%
H_NURSE_EXPLAIN_SN_P: Nurses "sometimes" or "never" explained things so they could understand 4%
H_NURSE_EXPLAIN_U_P: Nurses "usually" explained things so they could understand 19%
H_COMP_2_A_P: Doctors "always" communicated well 84%
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 3%
H_COMP_2_U_P: Doctors "usually" communicated well 13%
H_COMP_2_LINEAR_SCORE: Doctor communication - linear mean score
H_COMP_2_STAR_RATING: Doctor communication - star rating 4
H_DOCTOR_RESPECT_A_P: Doctors "always" treated them with courtesy and respect 90%
H_DOCTOR_RESPECT_SN_P: Doctors "sometimes" or "never" treated them with courtesy and respect 2%
H_DOCTOR_RESPECT_U_P: Doctors "usually" treated them with courtesy and respect 8%
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 83%
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 3%
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 14%
H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand 79%
H_DOCTOR_EXPLAIN_SN_P: Doctors "sometimes" or "never" explained things so they could understand 4%
H_DOCTOR_EXPLAIN_U_P: Doctors "usually" explained things so they could understand 17%
H_COMP_5_A_P: Staff "always" explained 64%
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 18%
H_COMP_5_U_P: Staff "usually" explained 18%
H_COMP_5_LINEAR_SCORE: Communication about medicines - linear mean score
H_COMP_5_STAR_RATING: Communication about medicines - star rating 3
H_MED_FOR_A_P: Staff "always" explained new medications 76%
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications 8%
H_MED_FOR_U_P: Staff "usually" explained new medications 16%
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 51%
H_SIDE_EFFECTS_SN_P: Staff "sometimes" or "never" explained possible side effects 28%
H_SIDE_EFFECTS_U_P: Staff "usually" explained possible side effects 21%
H_COMP_6_N_P: No, staff "did not" give patients this information 10%
H_COMP_6_Y_P: Yes, staff "did" give patients this information 90%
H_COMP_6_LINEAR_SCORE: Discharge information - linear mean score
H_COMP_6_STAR_RATING: Discharge information - star rating 4
H_DISCH_HELP_N_P: No, staff "did not" give patients information about help after discharge 11%
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 89%
H_SYMPTOMS_N_P: No, staff "did not" give patients information about possible symptoms 9%
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 91%
H_CLEAN_HSP_A_P: Room was "always" clean 74%
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 9%
H_CLEAN_HSP_U_P: Room was "usually" clean 17%
H_CLEAN_LINEAR_SCORE: Cleanliness - linear mean score
H_CLEAN_STAR_RATING: Cleanliness - star rating 3
H_QUIET_HSP_A_P: "Always" quiet at night 57%
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 12%
H_QUIET_HSP_U_P: "Usually" quiet at night 31%
H_QUIET_LINEAR_SCORE: Quietness - linear mean score
H_QUIET_STAR_RATING: Quietness - star rating 3
H_HSP_RATING_0_6: Patients who gave a rating of "6" or lower (low) 5%
H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium) 14%
H_HSP_RATING_9_10: Patients who gave a rating of "9" or "10" (high) 81%
H_HSP_RATING_LINEAR_SCORE: Overall hospital rating - linear mean score
H_HSP_RATING_STAR_RATING: Overall hospital rating - star rating 4
H_RECMND_DN: "NO", patients would not recommend the hospital (they probably would not or definitely would not recommend it) 2%
H_RECMND_DY: "YES", patients would definitely recommend the hospital 84%
H_RECMND_PY: "YES", patients would probably recommend the hospital 14%
H_RECMND_LINEAR_SCORE: Recommend hospital - linear mean score
H_RECMND_STAR_RATING: Recommend hospital - star rating 5
H_STAR_RATING: Summary star rating 4

Healthcare Associated Infections

Standardized Infection Ratios (SIR). A SIR < 1.0 means fewer infections than predicted based on national baseline data.

Measure Score (SIR) vs. National
HAI_1_CILOWER
HAI_1_CIUPPER
HAI_1_DOPC 1467.000
HAI_1_ELIGCASES 0.904
HAI_1_NUMERATOR 0.000
HAI_1_SIR
HAI_2_CILOWER
HAI_2_CIUPPER
HAI_2_DOPC 1287.000
HAI_2_ELIGCASES 0.708
HAI_2_NUMERATOR 1.000
HAI_2_SIR
HAI_3_CILOWER N/A No Different than National Benchmark
HAI_3_CIUPPER 1.462 No Different than National Benchmark
HAI_3_DOPC 77.000 No Different than National Benchmark
HAI_3_ELIGCASES 2.049 No Different than National Benchmark
HAI_3_NUMERATOR 0.000 No Different than National Benchmark
HAI_3_SIR 0.000 No Different than National Benchmark
HAI_4_CILOWER
HAI_4_CIUPPER
HAI_4_DOPC 119.000
HAI_4_ELIGCASES 0.995
HAI_4_NUMERATOR 2.000
HAI_4_SIR
HAI_5_CILOWER
HAI_5_CIUPPER
HAI_5_DOPC 11355.000
HAI_5_ELIGCASES 0.381
HAI_5_NUMERATOR 0.000
HAI_5_SIR
HAI_6_CILOWER 0.432 No Different than National Benchmark
HAI_6_CIUPPER 2.615 No Different than National Benchmark
HAI_6_DOPC 10439.000 No Different than National Benchmark
HAI_6_ELIGCASES 4.238 No Different than National Benchmark
HAI_6_NUMERATOR 5.000 No Different than National Benchmark
HAI_6_SIR 1.180 No Different than National Benchmark

Timely & Effective Care

Process-of-care measures including ED wait times, treatment timeliness, and preventive care.

Measure Score Condition
EDV medium Emergency Department
GMCS Electronic Clinical Quality Measure
GMCS_Malnutrition_Diagnosis_Documented Electronic Clinical Quality Measure
GMCS_Malnutrition_Screening Electronic Clinical Quality Measure
GMCS_Nutrition_Assessment Electronic Clinical Quality Measure
GMCS_Nutritional_Care_Plan Electronic Clinical Quality Measure
HH_HYPER 2.0 Electronic Clinical Quality Measure
HH_HYPO 0.0 Electronic Clinical Quality Measure
HH_ORAE Electronic Clinical Quality Measure
IMM_3 83.0 Healthcare Personnel Vaccination
OP_18a 142.0 Emergency Department
OP_18b 143.0 Emergency Department
OP_18c 126.0 Emergency Department
OP_18d Emergency Department
OP_22 2.0 Emergency Department
OP_23 Emergency Department
OP_29 100.0 Colonoscopy care
OP_31 Cataract surgery outcome
OP_40 Electronic Clinical Quality Measure
SAFE_USE_OF_OPIOIDS 15.0 Electronic Clinical Quality Measure
SEP_1 74.0 Sepsis Care
SEP_SH_3HR 90.0 Sepsis Care
SEP_SH_6HR 65.0 Sepsis Care
SEV_SEP_3HR 89.0 Sepsis Care
SEV_SEP_6HR 94.0 Sepsis Care
STK_02 Electronic Clinical Quality Measure
STK_03 Electronic Clinical Quality Measure
STK_05 Electronic Clinical Quality Measure
VTE_1 95.0 Electronic Clinical Quality Measure
VTE_2 95.0 Electronic Clinical Quality Measure

Unplanned Hospital Visits

Readmission and ED return rates within 30 days of discharge.

Measure Score vs. National
EDAC_30_AMI Number of Cases Too Small
EDAC_30_HF -34.30 Fewer Days Than Average per 100 Discharges
EDAC_30_PN -1.20 Average Days per 100 Discharges
Hybrid_HWR 14.00 No Different Than the National Rate
OP_32 12.50 No Different Than the National Rate
OP_35_ADM 10.70 No Different Than the National Rate
OP_35_ED 5.10 No Different Than the National Rate
OP_36 1.00 No Different than expected
READM_30_AMI Number of Cases Too Small
READM_30_CABG
READM_30_COPD Number of Cases Too Small
READM_30_HF 19.00 No Different Than the National Rate
READM_30_HIP_KNEE 4.30 No Different Than the National Rate
READM_30_PN 15.50 No Different Than the National Rate

Medicare Spending Per Beneficiary

MSPB ratio: values > 1.0 mean this hospital's episode spending is higher than the national median hospital.

Value
0.97

Financial Health (Cost Report — FY 2023)

All Data

Every labeled metric surfaced for this hospital, with national medians and percentiles where a benchmark is available.

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Show 76 rows
Source Metric Value National Median Pctl. Raw key
Cost Report Cost-to-Charge Ratio 0.21 metrics.cost_to_charge_ratio
Cost Report Current Ratio 2.03 metrics.current_ratio
Cost Report Employees per Bed 23.61 metrics.employees_per_bed
Cost Report fiscal_year 2,023 fiscal_year
Cost Report Fund Balance ($) $68,918,525 metrics.fund_balance
Cost Report Net Income ($) $6,153,664 metrics.net_income
Cost Report Net Patient Revenue ($) $237,329,870 metrics.net_patient_revenue
Cost Report Operating Margin (%) -2.9% metrics.operating_margin
Cost Report Total Assets ($) $242,310,453 metrics.total_assets
Cost Report Total Costs ($) $154,024,402 metrics.total_costs
Cost Report Total Liabilities ($) $173,391,928 metrics.total_liabilities
Cost Report Total Margin (%) 2.5% metrics.total_margin
Cost Report Uncompensated Care (%) 2.8% metrics.uncompensated_care_pct
General Information Address 2351 'G' RD Address
General Information City/Town GRAND JUNCTION City/Town
General Information Count of Facility MORT Measures 3 Count of Facility MORT Measures
General Information Count of Facility Pt Exp Measures 8 Count of Facility Pt Exp Measures
General Information Count of Facility READM Measures 8 Count of Facility READM Measures
General Information Count of Facility Safety Measures 4 Count of Facility Safety Measures
General Information Count of Facility TE Measures 10 Count of Facility TE Measures
General Information Count of MORT Measures Better 0 Count of MORT Measures Better
General Information Count of MORT Measures No Different 3 Count of MORT Measures No Different
General Information Count of MORT Measures Worse 0 Count of MORT Measures Worse
General Information Count of READM Measures Better 1 Count of READM Measures Better
General Information Count of READM Measures No Different 6 Count of READM Measures No Different
General Information Count of READM Measures Worse 1 Count of READM Measures Worse
General Information Count of Safety Measures Better 0 Count of Safety Measures Better
General Information Count of Safety Measures No Different 4 Count of Safety Measures No Different
General Information Count of Safety Measures Worse 0 Count of Safety Measures Worse
General Information County/Parish MESA County/Parish
General Information Emergency Services Yes Emergency Services
General Information Facility ID 060054 Facility ID
General Information Facility Name COMMUNITY HOSPITAL Facility Name
General Information Hospital overall rating 4 Hospital overall rating
General Information Hospital overall rating footnote Hospital overall rating footnote
General Information Hospital Ownership Voluntary non-profit - Private Hospital Ownership
General Information Hospital Type Acute Care Hospitals Hospital Type
General Information Meets criteria for birthing friendly designation Y Meets criteria for birthing friendly designation
General Information MORT Group Footnote MORT Group Footnote
General Information MORT Group Measure Count 7 MORT Group Measure Count
General Information Pt Exp Group Footnote Pt Exp Group Footnote
General Information Pt Exp Group Measure Count 8 Pt Exp Group Measure Count
General Information READM Group Footnote READM Group Footnote
General Information READM Group Measure Count 11 READM Group Measure Count
General Information Safety Group Footnote Safety Group Footnote
General Information Safety Group Measure Count 8 Safety Group Measure Count
General Information State CO State
General Information TE Group Footnote TE Group Footnote
General Information TE Group Measure Count 12 TE Group Measure Count
General Information Telephone Number (970) 644-3011 Telephone Number
General Information ZIP Code 81505 ZIP Code
HAC Reduction Program fiscal_year 2,026 fiscal_year
HAC Reduction Program measures — cauti — sir 0 measures.cauti.sir
HAC Reduction Program measures — cdi — sir 0.74 measures.cdi.sir
HAC Reduction Program measures — clabsi — sir 1.07 measures.clabsi.sir
HAC Reduction Program measures — ssi — sir 1.74 measures.ssi.sir
HAC Reduction Program payment_reduction Yes payment_reduction
HAC Reduction Program total_hac_score 0.63 total_hac_score
Medicare Spending per Beneficiary End Date 12/31/2024 End Date
Medicare Spending per Beneficiary Measure ID MSPB-1 Measure ID
Medicare Spending per Beneficiary Start Date 01/01/2024 Start Date
Medicare Spending per Beneficiary Value 0.97 Value
Readmissions (HRRP) Heart Failure — Excess readmission ratio 0.96 0.9983 p27 READM-30-HF-HRRP.excess_readmission_ratio
Readmissions (HRRP) Heart Failure — Expected readmission rate 17.0% READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Predicted readmission rate 16.4% READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Hip/Knee Replacement — Excess readmission ratio 0.88 0.9916 p19 READM-30-HIP-KNEE-HRRP.excess_readmission_ratio
Readmissions (HRRP) Hip/Knee Replacement — Expected readmission rate 5.8% READM-30-HIP-KNEE-HRRP.expected_readmission_rate
Readmissions (HRRP) Hip/Knee Replacement — Predicted readmission rate 5.1% READM-30-HIP-KNEE-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 0.97 0.9955 p31 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 13.7% READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Predicted readmission rate 13.3% READM-30-PN-HRRP.predicted_readmission_rate
Value-Based Purchasing Clinical Outcomes 0.00 5.00 p0 clinical_outcomes_score
Value-Based Purchasing Efficiency & Cost Reduction 7.50 2.50 p67 efficiency_score
Value-Based Purchasing Person & Community Engagement 16.75 8.75 p89 person_community_score
Value-Based Purchasing Safety 3.33 10.00 p5 safety_score
Value-Based Purchasing Total Performance Score 27.58 29.50 p43 total_performance_score
Methodology

Full methodology →