P&P, Paid & Penalized

Public Medicare data, made visible.

HospitalLegacy Mount Hood Medical Center Estimated FY2026 net: −$76K×

Hospital record · FY2026CCN 380025

1Hospital

Legacy Mount Hood Medical Center

2Location

Gresham, OR (Oregon’s hospitals on the map and in the table) 97030

Multnomah County

3Type

Not a teaching hospital · 115 beds · Nonprofit · Urban

4Care Compare stars

3 of 5 stars

Overall rating, CMS Care Compare data of July 22, 2026
Open on Care Compare (opens in a new tab)

5Total HAC Score

0.7341

As CMS reports it

6Payment reduction

1% cut
CMS’s value: Yes

7Estimated cut

$135K estimate
Likely $99⁠–⁠167K; about $174 per traditional Medicare stay

Cut 1%

$135K

cut from its FY2026 Medicare inpatient payments, this site estimates estimate

For fiscal year 2026, CMS reports a Total HAC Score of 0.7341 for Legacy Mount Hood Medical Center and a payment reduction decision of Yes.

That is 1% of about $13.5M, this site’s estimate of what traditional Medicare pays it for inpatient stays in a year: about $174 per traditional Medicare stay.

Likely range $99–167K

Its score was above CMS’s line, so CMS cut its Medicare inpatient payments by 1% for the year. The score compares hospitals with each other; it is not a grade of the quality of care.

CMS cut scores of 0.3799 and above.

Each year CMS cuts the hospitals with the highest quarter of scores, those above the 75th percentile, so the line moves with other hospitals’ scores.

lowest −1.4728 highest 2.3133 1% cut Middle hospital: −0.0453 Middle hospital−0.0453 CMS’s line: 0.3799 and up CMS’s line0.3799 and up This hospital: 0.7341 This hospital 0.7341 lowest −1.4728 highest 2.3133 1% cut Middle hospital: −0.0453 Middle hospital−0.0453 CMS’s line: 0.3799 and up CMS’s line0.3799 and up This hospital: 0.7341 This hospital 0.7341

Higher than 88% of the other 2,928 scores CMS published (higher is worse).

Its record, fiscal years 2015 to 2026 Cut in 7 of 11 years

  1. 15Cut
  2. 16Cut
  3. 17No
  4. 18Cut
  5. 19Cut
  6. 20No
  7. 21No
  8. 22No
  9. 23—
  10. 24Cut
  11. 25Cut
  12. 26Cut

Where the score came from

CMS scored this hospital on all 6 measures. On every measure a lower value is better. Each row puts the hospital among every hospital with a value: the gray columns are those hospitals, the tall tick is the national median, and the hatched ends score the same as CMS’s floor or cap.

Bringing CAUTI down to the national median (0.489) would lower the score the most: by 0.4210, to 0.3131. That change alone would put the score under CMS’s line. Try it in the what-if

Figure 1. Of its 6 measures with a value, this hospital is above the national median on 4; CAUTI added the most to its score.
  • This hospital
  • National median
  • Scores the same as CMS’s floor or cap
  1. PSI 90 (what it counts)

    Safety problems such as serious bedsores, falls that break a bone and blood clots after surgery, found by CMS in traditional Medicare claims. A value of 1 matches the national composite value.

    Patient safety and adverse events composite

    Worse than 87% of the other 2,808 hospitals

    estimate

    This site recomputes this measure’s z‑score from CMS’s published value. The recompute can differ from CMS’s z‑score by up to 0.0021. How this site estimates

    CMS value1.1647

    Z-score1.2302

    Part of score+0.2050

  2. CLABSI (what it counts)

    Bloodstream infections tied to a central line, a tube often placed in a large vein in the neck, chest or groin. Hospitals report them to the CDC’s National Healthcare Safety Network. A value of 1.0 means as many infections as the CDC’s model predicted.

    Central line–associated bloodstream infections

    Worse than 71% of the other 2,181 hospitals

    CMS value0.814

    Z-score0.4818

    Part of score+0.0803

  3. CAUTI (what it counts)

    Urinary tract infections that start from a urinary catheter, a tube that drains the bladder. Hospitals report them to the CDC’s National Healthcare Safety Network. A value of 1.0 means as many infections as the CDC’s model predicted.

    added the most

    Catheter-associated urinary tract infections

    Worse than 98% of the other 2,354 hospitals

    CMS value2.227

    Z-score2.3863

    Part of score+0.3977

  4. SSI (what it counts)

    Deep infections at the site of colon surgery or an abdominal hysterectomy, within a month of the operation, pooled into one measure. Hospitals report them to the CDC’s National Healthcare Safety Network. A value of 1.0 means as many infections as the CDC’s model predicted.

    Surgical site infections after colon surgery or abdominal hysterectomy

    Better than 57% of the other 2,269 hospitals

    CMS value0.687

    Z-score−0.2796

    Part of score−0.0466

  5. CDI (what it counts)

    C. diff infections, which cause diarrhea and inflammation of the colon, found by a lab test and starting in the hospital. Hospitals report them to the CDC’s National Healthcare Safety Network. A value of 1.0 means as many infections as the CDC’s model predicted.

    Clostridioides difficile (C. diff) infections

    Better than 50% of the other 2,766 hospitals

    estimate

    This site recomputes this measure’s z‑score from CMS’s published value. The recompute can differ from CMS’s z‑score by up to 0.0071. How this site estimates

    CMS value0.344

    Z-score−0.1302

    Part of score−0.0217

  6. MRSA (what it counts)

    Bloodstream infections with MRSA, a germ that resists several antibiotics, found by a lab test and starting in the hospital. Hospitals report them to the CDC’s National Healthcare Safety Network. A value of 1.0 means as many infections as the CDC’s model predicted.

    MRSA bloodstream infections

    Worse than 78% of the other 2,067 hospitals

    CMS value1.040

    Z-score0.7162

    Part of score+0.1194

Source: CMS Provider Data Catalog, HACRP FY2026 (yq43-i98g), released August 13, 2026.

Show table
MeasureCMS valueNational medianZ-scorePart of the scoreAmong hospitals
PSI 901.16470.96231.2302+0.2050Worse than 87% of the other 2,808 hospitals
CLABSI0.8140.5590.4818+0.0803Worse than 71% of the other 2,181 hospitals
CAUTI2.2270.4892.3863+0.3977Worse than 98% of the other 2,354 hospitals
SSI0.6870.795−0.2796−0.0466Better than 57% of the other 2,269 hospitals
CDI0.3440.346−0.1302−0.0217Better than 50% of the other 2,766 hospitals
MRSA1.0400.6410.7162+0.1194Worse than 78% of the other 2,067 hospitals

How the parts add up

CMS adds the z‑scores and divides by the number of measures scored, so each measure counts the same. Each bar below is one z‑score divided by 6; a bar right of zero raised the score and one left of zero lowered it.

(1.2302PSI 90+0.4818CLABSI+2.3863CAUTI−0.2796SSI−0.1302CDI+0.7162MRSA)÷6measures=0.7341Total HAC Score

This hospital’s score is 0.3549 above 0.3792, the highest score CMS marked No. (This site recomputes.)

Figure 2. The parts add up to 0.7341, above CMS’s line.
1% cut PSI 90: z‑score 1.2302 divided by 6 = +0.2050PSI 90+0.2050 CLABSI: z‑score 0.4818 divided by 6 = +0.0803CLABSI+0.0803 CAUTI: z‑score 2.3863 divided by 6 = +0.3977CAUTI+0.3977 SSI: z‑score −0.2796 divided by 6 = −0.0466SSI−0.0466 CDI: z‑score −0.1302 divided by 6 = −0.0217CDI−0.0217 MRSA: z‑score 0.7162 divided by 6 = +0.1194MRSA+0.1194 Total HAC Score: 0.7341Score0.7341 CMS’s line: between 0.3792 and 0.3799 CMS’s line 0.00.20.40.60.8 1% cut PSI 90: z‑score 1.2302 divided by 6 = +0.2050PSI 90+0.2050 CLABSI: z‑score 0.4818 divided by 6 = +0.0803CLABSI+0.0803 CAUTI: z‑score 2.3863 divided by 6 = +0.3977CAUTI+0.3977 SSI: z‑score −0.2796 divided by 6 = −0.0466SSI−0.0466 CDI: z‑score −0.1302 divided by 6 = −0.0217CDI−0.0217 MRSA: z‑score 0.7162 divided by 6 = +0.1194MRSA+0.1194 Total HAC Score: 0.7341Score0.7341 CMS’s line: between 0.3792 and 0.3799 CMS’s line 0.00.20.40.60.8

This site recomputes · Source: CMS Provider Data Catalog, HACRP FY2026 (yq43-i98g), released August 13, 2026.

Show table
MeasureZ-scorePart of the scoreRunning total
PSI 901.2302+0.20500.2050
CLABSI0.4818+0.08030.2853
CAUTI2.3863+0.39770.6830
SSI−0.2796−0.04660.6364
CDI−0.1302−0.02170.6147
MRSA0.7162+0.11940.7341
Total HAC Score0.7341
CMS’s line0.37920.3799

The money is a cliff

This program’s cut doesn’t grow with the score. Over CMS’s line, CMS cuts 1% of what traditional Medicare pays a hospital for inpatient stays that year; at or under the line, this program cuts nothing.

The chart draws what the cut would be for this hospital at any Total HAC Score, from this site’s estimate of its payments, with its own score marked.

Figure 3. The cut is a cliff, not a slope: this hospital’s score, 0.3549 over the highest score CMS didn’t cut, costs it about $135K by this site’s estimate, and at CMS’s highest score, 2.3133, the cut would be the same.
CMS’s line $0 at any score up to 0.3792 $135K at any score from 0.3799 $0at any score up to 0.3792 $135K at any score from 0.3799 −1012 CMS’s highest score: 2.3133 This hospital: 0.7341 This hospital 0.7341 CMS’s line $0 at any score up to 0.3792 $135K at any score from 0.3799 $0at any score up to 0.3792 $135Kat any score from 0.3799 −1.0−0.50.00.51.01.52.0 CMS’s highest score: 2.3133 CMS’s highest score 2.3133 This hospital: 0.7341 This hospital 0.7341

Under the axis, every Total HAC Score CMS published: 306 of the 2,929 scored within 0.1 of CMS’s line, on one side or the other.

Estimate · Source: this site’s arithmetic on CMS’s FY2026 IPPS final rule files (the impact file, the rate tables and the value-based factors), its FY2026 HRRP supplemental file and HACRP FY2026 (yq43-i98g), released August 13, 2026.

Show table
ScoreTotal HAC ScoreEstimated HAC cut (whole dollars)
Any score up to 0.37920.3792$0
Any score from 0.37990.3799−$134,675
This hospital0.7341−$134,675
CMS’s highest score2.3133−$134,675

The money, line by line

This site estimates what traditional Medicare pays the hospital for a year of inpatient stays, from CMS’s FY2026 payment files, then applies Medicare’s three hospital quality programs: the readmissions and value-based adjustments to the base payment, and the HAC cut last, as the law sets.

The readmissions and value-based programs adjust only the base payment: the DRG rates times the hospital’s cases, and a Medicare-dependent hospital’s add-on. The HAC cut comes last and takes 1% of everything left, teaching, low-income-patient, outlier, capital and uncompensated care payments included.

($13,408,641payment+$0readmissions+$58,905value-based)×1%the cut=$134,675HAC cut

$134,675HAC cut÷774traditional Medicare stays=$174per traditional Medicare stay

Figure 4. This site estimates the HAC cut at $135K: 1% of the hospital’s whole inpatient payment, taken last. The readmissions and value-based adjustments, on the base alone, came to $0 and +$59K.

Estimated Medicare inpatient payments · FY2026 estimate

What traditional Medicare pays it for inpatient stays
DRG payments at the federal rates the base $9,363,338
Many low-income patients (disproportionate share) $280,900
Outliers: unusually costly stays $900,285
Capital: buildings and equipment $735,295
Uncompensated care $2,128,823
Total, before the three programs $13,408,641
The three programs: two on the base, the HAC cut last
Readmissions (HRRP) base × (1.0000 − 1) $0
Value-based purchasing (HVBP) base × (1.0063 − 1) +$58,905
After these two $13,467,546
HAC Reduction Program 1% of everything above; likely $99⁠–⁠167K −$134,675
Net of the three programs likely −$97K to −$55K −$75,770

Not paid to this hospital: a Medicare-dependent hospital add-on, teaching payments, a sole community hospital rate difference, and a low-volume adjustment.

Whole dollars, so every line adds up; the estimate is not that precise. Each likely range spans the middle 80% of the misses this site’s estimate made for similar hospitals (or for a wider group, where there were too few) when it was checked against their FY2024 cost reports: one year’s check, not a promise of how often a hospital’s actual figure lands inside.

Estimate · Source: this site’s arithmetic on CMS’s FY2026 IPPS final rule files (the impact file, the rate tables and the value-based factors), its FY2026 HRRP supplemental file and HACRP FY2026 (yq43-i98g), released August 13, 2026.

Show table
LineAmount (whole dollars)
DRG payments at the federal rates (the base)$9,363,338
Many low-income patients (disproportionate share)$280,900
Outliers: unusually costly stays$900,285
Capital: buildings and equipment$735,295
Uncompensated care$2,128,823
Total, before the three programs$13,408,641
Readmissions (HRRP) (base × (1.0000 − 1))$0
Value-based purchasing (HVBP) (base × (1.0063 − 1))+$58,905
After these two$13,467,546
HAC Reduction Program (1% of everything above; likely $99–167K)−$134,675
Net of the three programs (likely −$97K to −$55K)−$75,770

What if a measure were different?

Change a measure’s value to see how this site recomputes the Total HAC Score, the payment reduction decision and, by its estimate, the money, starting from CMS’s values. The money doesn’t slide with the score: it drops off a cliff at CMS’s line.

The what-if needs JavaScript. Without it, the values below stay as they are.

Show table
CMS reportsHypothetical
Total HAC Score0.7341same
Payment reduction decisionYessame
Payment cut1%same
Estimated HAC cut estimate$135Ksame

CMS’s line: between 0.3792 and 0.3799

The faint ticks are CMS’s line in earlier years under the same formula, from about 0.300 (FY2022) to about 0.375 (FY2024). The line moves every year, so a hospital can cross it without changing anything.

CMS reports a Total HAC Score of 0.7341 and a payment reduction decision of Yes.

A what-if shows the formula’s arithmetic, not what a hospital could realistically change or how. CMS’s real result also depends on other hospitals.

What would it take?

Getting under CMS’s line would keep about $135K, this site estimates: the whole cut, however far under the score lands.

From CMS’s values, one measure at a time, with every other measure held at CMS’s value.

MeasureValue that would read No
PSI 900.8596 or lower
CLABSInot possible with this measure alone
CAUTI0.653 or lower
SSInot possible with this measure alone
CDInot possible with this measure alone
MRSA0.021 or lower

Each measure weighs 1 ÷ 6 of the score.

Measure values

SIR 1.0 = as many infections as predicted · Lower is better

On each track the tick is the national median; shaded values score the same as the floor or cap, as this site fits them to CMS’s values.

CMS 1.1647 · median 0.9623 · floor 0.7760 · cap 1.3482 · each 0.1 = 0.1164

CMS 0.814 · median 0.559 · cap 1.572 · each 0.1 = 0.0387

CMS 2.227 · median 0.489 · cap 1.537 · each 0.1 = 0.0402

CMS 0.687 · median 0.795 · cap 2.118 · each 0.1 = 0.0286

CMS 0.344 · median 0.346 · cap 0.944 · each 0.1 = 0.0645

CMS 1.040 · median 0.641 · cap 1.762 · each 0.1 = 0.0348

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Figure 5. CAUTI added the most to this hospital’s Total HAC Score of 0.7341 among its measured results: +0.3977.
  • PSI 90 +0.2050
  • CLABSI +0.0803
  • CAUTI +0.3977
  • SSI −0.0466
  • CDI −0.0217
  • MRSA +0.1194

A measure adds its z‑score divided by 6, the number of measures scored. Bars right of the center line raise the score. Hatched: assigned by CMS.

This site recomputes · Source: CMS Provider Data Catalog, HACRP FY2026 (yq43-i98g), released August 13, 2026.

Show table
MeasureZ-scorePart of the scoreHypothetical
PSI 901.2302+0.2050same
CLABSI0.4818+0.0803same
CAUTI2.3863+0.3977same
SSI−0.2796−0.0466same
CDI−0.1302−0.0217same
MRSA0.7162+0.1194same

Interactive what-if at https://paidandpenalized.org/hacrp/hospital/380025/

Among hospitals with a Yes or No payment decision, CMS cut those with a published Total HAC Score of 0.3799 or higher and none at 0.3792 or lower. Maryland’s hospitals are scored but not subject to the reduction.

Held fixed: every other hospital’s results, CMS’s line, and each measure’s mean, spread, floor and cap as this site fits them to CMS’s published values.

Year by year

Where this hospital’s score fell among every hospital’s, each year CMS published one. A score near the top is among the highest; the shaded band is where CMS cut. Places compare across years even where CMS changed how it builds the score.

Its longest run: cut 3 years in a row.

Figure 6. CMS cut this hospital in 7 of the 11 years it made a decision.
highest middle lowest z‑scoresequal weights no scores FY2015: score 8.9750, higher than 95% of scores; cutFY2016: score 7.2500, higher than 81% of scores; cutFY2017: score 6.3600, higher than 71% of scores; not cutFY2018: score 0.8010, higher than 90% of scores; cutFY2019: score 1.1262, higher than 95% of scores; cutFY2020: score 0.1642, higher than 64% of scores; not cutFY2021: score −0.5081, higher than 19% of scores; not cutFY2022: score −0.0104, higher than 51% of scores; not cutFY2024: score 0.5269, higher than 81% of scores; cutFY2025: score 1.1242, higher than 95% of scores; cutFY2026: score 0.7341, higher than 88% of scores; cut 161820222426 highest middle lowest z‑scoresequal weights no scores FY2015: score 8.9750, higher than 95% of scores; cutFY2016: score 7.2500, higher than 81% of scores; cutFY2017: score 6.3600, higher than 71% of scores; not cutFY2018: score 0.8010, higher than 90% of scores; cutFY2019: score 1.1262, higher than 95% of scores; cutFY2020: score 0.1642, higher than 64% of scores; not cutFY2021: score −0.5081, higher than 19% of scores; not cutFY2022: score −0.0104, higher than 51% of scores; not cutFY2024: score 0.5269, higher than 81% of scores; cutFY2025: score 1.1242, higher than 95% of scores; cutFY2026: score 0.7341, higher than 88% of scores; cut 151617181920212223242526

● Red: a year CMS cut it ○ Hollow: a year it didn’t

This site recomputes · Source: CMS, HACRP hospital files for fiscal years 2015 to 2026 (Provider Data Catalog, its archives and, for the oldest years, the Internet Archive’s copies), and CMS’s cut lists for FY2015 and FY2016.

Show table
Fiscal yearTotal HAC ScoreHigher than this share of scoresPayment reduction
FY20158.975095.7%cut
FY20167.250081.2%cut
FY20176.360071.5%not cut
FY20180.801090.6%cut
FY20191.126295.7%cut
FY20200.164264.9%not cut
FY2021−0.508119.4%not cut
FY2022−0.010451.7%not cut
FY2023no decision
FY20240.526981.3%cut
FY20251.124295.7%cut
FY20260.734188.1%cut

Its infections, year by year

This hospital’s infection rate against prediction for each calendar year Care Compare published one, on each measure with at least two years of results (black), over the nation’s middle hospital (gray). Below the dashed line at one, fewer infections than predicted. Each year is measured against the same fixed baseline, not against other hospitals, so unlike the score they can all improve at once.

Figure 7. 5 of its 5 infection measures ended lower than they started.
CLABSI 1.34 → 0.00 1as predicted 0 ’18’21’24 Nation’s middle CLABSI, 2017: 1.344CLABSI, 2018: 0.000CLABSI, 2019: 1.552CLABSI, 2021: 1.734CLABSI, 2022: 0.477CLABSI, 2023: 1.695CLABSI, 2024: 0.000 CAUTI 2.98 → 1.88 1 0 ’18’21’24 CAUTI, 2017: 2.982CAUTI, 2018: 0.722CAUTI, 2019: 0.600CAUTI, 2021: 0.452CAUTI, 2022: 1.288CAUTI, 2023: 2.541CAUTI, 2024: 1.879 SSI, colon 1.92 → 0.34 1 0 ’18’21’24 SSI, colon, 2017: 1.916SSI, colon, 2018: 0.802SSI, colon, 2019: 0.387SSI, colon, 2021: 0.350SSI, colon, 2022: 1.377SSI, colon, 2023: 1.093SSI, colon, 2024: 0.345 MRSA 0.96 → 0.93 1 0 ’18’21’24 MRSA, 2017: 0.961MRSA, 2018: 0.000MRSA, 2021: 0.739MRSA, 2022: 0.726MRSA, 2023: 0.928 C. diff 0.57 → 0.31 1 0 ’18’21’24 C. diff, 2017: 0.573C. diff, 2018: 0.255C. diff, 2019: 0.721C. diff, 2021: 0.636C. diff, 2022: 0.906C. diff, 2023: 0.376C. diff, 2024: 0.311 CLABSI 1.34 → 0.00 1as predicted 0 ’18’20’22’24 Nation’s middle CLABSI, 2017: 1.344CLABSI, 2018: 0.000CLABSI, 2019: 1.552CLABSI, 2021: 1.734CLABSI, 2022: 0.477CLABSI, 2023: 1.695CLABSI, 2024: 0.000 CAUTI 2.98 → 1.88 1 0 ’18’20’22’24 CAUTI, 2017: 2.982CAUTI, 2018: 0.722CAUTI, 2019: 0.600CAUTI, 2021: 0.452CAUTI, 2022: 1.288CAUTI, 2023: 2.541CAUTI, 2024: 1.879 SSI, colon 1.92 → 0.34 1 0 ’18’20’22’24 SSI, colon, 2017: 1.916SSI, colon, 2018: 0.802SSI, colon, 2019: 0.387SSI, colon, 2021: 0.350SSI, colon, 2022: 1.377SSI, colon, 2023: 1.093SSI, colon, 2024: 0.345 MRSA 0.96 → 0.93 1 0 ’18’20’22’24 MRSA, 2017: 0.961MRSA, 2018: 0.000MRSA, 2021: 0.739MRSA, 2022: 0.726MRSA, 2023: 0.928 C. diff 0.57 → 0.31 1 0 ’18’20’22’24 C. diff, 2017: 0.573C. diff, 2018: 0.255C. diff, 2019: 0.721C. diff, 2021: 0.636C. diff, 2022: 0.906C. diff, 2023: 0.376C. diff, 2024: 0.311

Source: CMS Care Compare, healthcare-associated infections by hospital, calendar years 2017 to 2024 (Provider Data Catalog archives; the oldest year through the Internet Archive’s copy).

Show table
Calendar yearCLABSICAUTISSI, colonMRSAC. diff
20171.3442.9821.9160.9610.573
20180.0000.7220.8020.0000.255
20191.5520.6000.3870.721
20211.7340.4520.3500.7390.636
20220.4771.2881.3770.7260.906
20231.6952.5411.0930.9280.376
20240.0001.8790.3450.311

Among hospitals like it

Each row is a group this hospital belongs to, drawn from every hospital in it with a payment decision. Red columns are hospitals past CMS’s line, the ones CMS cut; the short tick is the group’s middle score.

In Oregon, its score is higher than 80% of the other 31 scored there.

In Portland-Vancouver-Hillsboro, OR-WA area, its score is higher than 81% of the other 16 scored there.

Figure 8. Its score is above the middle in all 8 groups it belongs to; the share cut runs from 23% (Urban) to 47% (Portland-Vancouver-Hillsboro, OR-WA area).
All hospitals: CMS cut 718 of 2,886 (25%); middle score −0.0453All hospitals 2,886 hospitals25% cut West region: CMS cut 157 of 593 (26%); middle score −0.0302West region 593 hospitals26% cut Oregon: CMS cut 13 of 32 (41%); middle score 0.2424Oregon 32 hospitals41% cut Portland-Vancouver-Hillsboro, OR-WA area: CMS cut 8 of 17 (47%); middle score 0.3761Portland-Vancouver-Hillsboro, OR-WA area17 hospitals47% cut Not teaching: CMS cut 389 of 1,563 (25%); middle score −0.1053Not teaching 1,563 hospitals25% cut 100 to 299 beds: CMS cut 275 of 1,193 (23%); middle score −0.0732100 to 299 beds 1,193 hospitals23% cut Nonprofit: CMS cut 478 of 1,830 (26%); middle score −0.0134Nonprofit 1,830 hospitals26% cut Urban: CMS cut 510 of 2,241 (23%); middle score −0.0574Urban 2,241 hospitals23% cut CMS’s line: between 0.3792 and 0.3799 CMS’s line −1012 This hospital: 0.7341 This hospital 0.7341 All hospitals: CMS cut 718 of 2,886 (25%); middle score −0.0453All hospitals2,886 hospitals25% cut West region: CMS cut 157 of 593 (26%); middle score −0.0302West region593 hospitals26% cut Oregon: CMS cut 13 of 32 (41%); middle score 0.2424Oregon32 hospitals41% cut Portland-Vancouver-Hillsboro, OR-WA area: CMS cut 8 of 17 (47%); middle score 0.3761Portland-Vancouver-Hillsboro, OR-WA area17 hospitals47% cut Not teaching: CMS cut 389 of 1,563 (25%); middle score −0.1053Not teaching1,563 hospitals25% cut 100 to 299 beds: CMS cut 275 of 1,193 (23%); middle score −0.0732100 to 299 beds1,193 hospitals23% cut Nonprofit: CMS cut 478 of 1,830 (26%); middle score −0.0134Nonprofit1,830 hospitals26% cut Urban: CMS cut 510 of 2,241 (23%); middle score −0.0574Urban2,241 hospitals23% cut CMS’s line: between 0.3792 and 0.3799 CMS’s line −1.5−1.0−0.50.00.51.01.52.0 This hospital: 0.7341 This hospital 0.7341

Source: CMS Provider Data Catalog, HACRP FY2026 (yq43-i98g), released August 13, 2026.

Show table
GroupWith a decisionHospitals cutShare cutMiddle scoreHospital higher than
All hospitals2,88671825%−0.045388%
West region59315726%−0.030288%
Oregon321341%0.242480%
Portland-Vancouver-Hillsboro, OR-WA area17847%0.376181%
Not teaching1,56338925%−0.105386%
100 to 299 beds1,19327523%−0.073291%
Nonprofit1,83047826%−0.013488%
Urban2,24151023%−0.057490%
This hospital0.7341
CMS’s line0.37920.3799

The nearest hospitals

The 8 closest hospitals with a Total HAC Score, in a straight line. The squares are each hospital’s measures in order: filled, above the national median; open, at or below it; hatched, assigned by CMS; blank, not scored.

Figure 9. CMS cut 4 of the 8 nearest hospitals; the closest is 7 miles away.
5 mi10 mi8. Legacy Good Samaritan Medical Center, Portland: score 0.0174, not cut, 14 miles87. OHSU Hospital and Clinics, Portland: score 1.0194, cut, 13 miles76. Legacy Emanuel Medical Center, Portland: score 0.4646, cut, 13 miles65. Providence Milwaukie Hospital, Milwaukie: score 0.4619, cut, 12 miles54. Peacehealth Southwest Medical Cente, Vancouver: score 0.0429, not cut, 11 miles43. Providence Portland Medical Center, Portland: score −0.0715, not cut, 10 miles32. Kaiser Sunnyside Medical Center, Clackamas: score 0.4184, cut, 9 miles21. Adventist Health Portland, Portland: score −0.4087, not cut, 7 miles1This hospital: Legacy Mount Hood Medical Center

Source: CMS Provider Data Catalog, HACRP FY2026 (yq43-i98g), released August 13, 2026.

Show table
HospitalMilesScoreDecision
Adventist Health Portland, Portland, OR7−0.4087not cut
Kaiser Sunnyside Medical Center, Clackamas, OR90.4184cut
Providence Portland Medical Center, Portland, OR10−0.0715not cut
Peacehealth Southwest Medical Cente, Vancouver, WA110.0429not cut
Providence Milwaukie Hospital, Milwaukie, OR120.4619cut
Legacy Emanuel Medical Center, Portland, OR130.4646cut
OHSU Hospital and Clinics, Portland, OR131.0194cut
Legacy Good Samaritan Medical Center, Portland, OR140.0174not cut

#HospitalMilesScoreDecisionEst. cut ($, modeled)Measures
1Adventist Health PortlandPortland, OR7−0.4087No cut$0Above the national median on 4 of 6 measures
2Kaiser Sunnyside Medical CenterClackamas, OR90.41841% cut$203KAbove the national median on 4 of 6 measures
3Providence Portland Medical CenterPortland, OR10−0.0715No cut$0Above the national median on 2 of 6 measures
4Peacehealth Southwest Medical CenteVancouver, WA110.0429No cut$0Above the national median on 3 of 6 measures
5Providence Milwaukie HospitalMilwaukie, OR120.46191% cut$119KAbove the national median on 3 of 5 measures
6Legacy Emanuel Medical CenterPortland, OR130.46461% cut$599KAbove the national median on 5 of 6 measures
7OHSU Hospital and ClinicsPortland, OR131.01941% cut$2.1MAbove the national median on 6 of 6 measures
8Legacy Good Samaritan Medical CenterPortland, OR140.0174No cut$0Above the national median on 5 of 6 measures

Download all hospitals’ data (CSV) · Data dictionary · CMS’s dataset page

How the program works, and how to find another hospital

A penalty reflects how CMS’s formula scored relative performance; it is not a verdict on the quality of care.

Cite this page

Paid & Penalized. Legacy Mount Hood Medical Center, Gresham, OR: Hospital-Acquired Conditions, FY2026. https://paidandpenalized.org/hacrp/hospital/380025/. Source: CMS Provider Data Catalog, HACRP FY2026 (yq43-i98g), released August 13, 2026.