JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Church

Adventhealth Fish Memorial

5 / 5

At a glance

Adventhealth Fish Memorial carries a 5-star CMS overall rating — above the national norm. On healthcare-associated infection measures, it performs better than the national average on 6 and worse on 0.

Healthcare-Associated Infections

lower is better · 36 measures reported

Rates of infections patients can acquire while receiving care, such as central-line and catheter-associated infections, MRSA, and C. difficile.

MeasureScoreCompared to national
Central Line Associated Bloodstream Infection (ICU + select Wards): Lower Confidence Limit0.014Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit1.409Same as national
Central Line Associated Bloodstream Infection: Number of Device Days4242Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases3.501Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases1Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.286Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.013Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit1.304Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days4349Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases3.781Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases1Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.264Same as national
SSI - Colon Surgery: Lower Confidence Limit0.108Same as national
SSI - Colon Surgery: Upper Confidence Limit2.121Same as national
SSI - Colon Surgery: Number of Procedures116Same as national
SSI - Colon Surgery: Predicted Cases3.115Same as national
SSI - Colon Surgery: Observed Cases2Same as national
SSI - Colon Surgery0.642Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures55Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.498Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence Limit0.020Same as national
MRSA Bacteremia: Upper Confidence Limit1.948Same as national
MRSA Bacteremia: Patient Days55221Same as national
MRSA Bacteremia: Predicted Cases2.532Same as national
MRSA Bacteremia: Observed Cases1Same as national
MRSA Bacteremia0.395Same as national
Clostridium Difficile (C.Diff): Lower Confidence LimitBetter than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.129Better than national
Clostridium Difficile (C.Diff): Patient Days54009Better than national
Clostridium Difficile (C.Diff): Predicted Cases23.156Better than national
Clostridium Difficile (C.Diff): Observed Cases0Better than national
Clostridium Difficile (C.Diff)0.000Better than national

Complications & Deaths

lower is better · 20 measures reported

Rates of serious complications (like hip/knee replacement problems or accidental cuts during surgery) and 30-day mortality rates for common conditions.

MeasureScoreCompared to nationalSample
Rate of complications for hip/knee replacement patientsNot available
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate3.8Same as national1029
Death rate for heart attack patients10.9Same as national127
Death rate for CABG surgery patientsNot available
Death rate for COPD patients7.7Same as national104
Death rate for heart failure patients7.8Better than national403
Death rate for pneumonia patients15.1Same as national410
Death rate for stroke patients10.4Same as national138
Pressure ulcer rate0.36Same as national3940
Death rate among surgical inpatients with serious treatable complications138.87Same as national31
Iatrogenic pneumothorax rate0.27Same as national4608
In-hospital fall-associated fracture rate0.22Same as national4815
Postoperative hemorrhage or hematoma rate1.97Same as national498
Postoperative acute kidney injury requiring dialysis rate1.60Same as national124
Postoperative respiratory failure rate9.57Same as national122
Perioperative pulmonary embolism or deep vein thrombosis rate3.57Same as national508
Postoperative sepsis rate7.18Same as national125
Postoperative wound dehiscence rate1.65Same as national160
Abdominopelvic accidental puncture or laceration rate0.85Same as national785
CMS Medicare PSI 90: Patient safety and adverse events composite0.98Same as national

Unplanned Hospital Visits & Readmissions

lower is better · 14 measures reported

How often patients return to the hospital unexpectedly within 30 days of discharge — a marker of care quality and discharge planning.

MeasureScoreCompared to nationalSample
Hospital return days for heart attack patients49Not available98
Hospital return days for heart failure patients-15Not available455
Hospital return days for pneumonia patients-4Not available443
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.6Same as national1745
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)14Same as national232
Rate of inpatient admissions for patients receiving outpatient chemotherapyNot available
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapyNot available
Ratio of unplanned hospital visits after hospital outpatient surgery1Same as national233
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate14.9Same as national98
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients19.1Same as national117
Heart failure (HF) 30-Day Readmission Rate19.4Same as national455
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate15.1Same as national443

Patient Experience (HCAHPS)

higher is better · 9 measures reported

What patients say about their hospital stay — communication with nurses and doctors, responsiveness, cleanliness, pain management, and whether they would recommend the hospital.

MeasureScoreSample
Nurse communication - star rating41770
Doctor communication - star rating31770
Communication about medicines - star rating41770
Discharge information - star rating41770
Cleanliness - star rating41770
Quietness - star rating41770
Overall hospital rating - star rating41770
Recommend hospital - star rating41770
Summary star rating41770

Timely & Effective Care

higher is better (unless a wait time) · 30 measures reported

How consistently hospitals follow recommended care processes — for example, giving heart-attack patients aspirin on arrival, or the average time spent in the emergency department.

MeasureScoreSample
Emergency department volumevery high
Global Malnutrition Composite Score
Global Malnutrition Composite Score: Malnutrition Diagnosis Documented
Global Malnutrition Composite Score: Malnutrition Risk Screening
Global Malnutrition Composite Score: Nutrition Assessment
Global Malnutrition Composite Score: Nutritional Care Plan
Hospital Harm - Severe Hyperglycemia
Hospital Harm - Severe Hypoglycemia14227
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination551799
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 better144432
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 better143423
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better
Left before being seen170577
Head CT results
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients7827
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing163045
Appropriate care for severe sepsis and septic shock82385
Septic Shock 3-Hour Bundle86132
Septic Shock 6-Hour Bundle9593
Severe Sepsis 3-Hour Bundle90387
Severe Sepsis 6-Hour Bundle99237
Discharged on Antithrombotic Therapy96251
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 2
Venous Thromboembolism Prophylaxis
Intensive Care Unit Venous Thromboembolism Prophylaxis982011

Maternal Health

lower is better · 4 measures reported

Measures of maternal outcomes and safe delivery practices, including severe complications during childbirth.

MeasureScoreSample
Cesarean Birth
Risk Adjusted Severe Obstetric Complications (All)
Risk Adjusted Severe Obstetric Complications (excluding blood-transfusion-only cases)
Maternal Morbidity Structural MeasureYes

Frequently asked questions

How is Adventhealth Fish Memorial rated?
Adventhealth Fish Memorial has a 5 out of 5 CMS overall star rating as of the latest CMS release.
Does Adventhealth Fish Memorial have emergency services?
Yes. Adventhealth Fish Memorial operates a 24/7 emergency department.
Where is Adventhealth Fish Memorial located?
Adventhealth Fish Memorial is located at 1055 Saxon Blvd, Orange City, FL 32763.
What type of hospital is Adventhealth Fish Memorial?
Adventhealth Fish Memorial is classified by CMS as a Acute Care Hospitals facility (Voluntary non-profit - Church).

Data as of 2026-06-14. Source: CMS Provider Data Catalog. This is public data provided for informational purposes only and is not medical advice. See our methodology and editorial policy.

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