JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Adventhealth Wesley Chapel

5 / 5

At a glance

Adventhealth Wesley Chapel 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 LimitSame as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit1.515Same as national
Central Line Associated Bloodstream Infection: Number of Device Days2137Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases1.978Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases0Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.000Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.087Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit1.720Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days3728Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases3.842Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases2Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.521Same as national
SSI - Colon Surgery: Lower Confidence Limit0.130Same as national
SSI - Colon Surgery: Upper Confidence Limit2.568Same as national
SSI - Colon Surgery: Number of Procedures101Same as national
SSI - Colon Surgery: Predicted Cases2.573Same as national
SSI - Colon Surgery: Observed Cases2Same as national
SSI - Colon Surgery0.777Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures48Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.451Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitSame as national
MRSA Bacteremia: Upper Confidence Limit1.334Same as national
MRSA Bacteremia: Patient Days51947Same as national
MRSA Bacteremia: Predicted Cases2.246Same as national
MRSA Bacteremia: Observed Cases0Same as national
MRSA Bacteremia0.000Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.059Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.447Better than national
Clostridium Difficile (C.Diff): Patient Days50449Better than national
Clostridium Difficile (C.Diff): Predicted Cases21.577Better than national
Clostridium Difficile (C.Diff): Observed Cases4Better than national
Clostridium Difficile (C.Diff)0.185Better 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 patients3.6Same as national45
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4Same as national1224
Death rate for heart attack patients11.6Same as national152
Death rate for CABG surgery patientsNot available
Death rate for COPD patients9.1Same as national104
Death rate for heart failure patients9.2Same as national369
Death rate for pneumonia patients13.9Same as national353
Death rate for stroke patients13Same as national113
Pressure ulcer rate0.70Same as national3673
Death rate among surgical inpatients with serious treatable complications146.02Same as national45
Iatrogenic pneumothorax rate0.17Same as national4803
In-hospital fall-associated fracture rate0.23Same as national4885
Postoperative hemorrhage or hematoma rate1.96Same as national839
Postoperative acute kidney injury requiring dialysis rate1.54Same as national325
Postoperative respiratory failure rate9.83Same as national313
Perioperative pulmonary embolism or deep vein thrombosis rate4.09Same as national895
Postoperative sepsis rate5.74Same as national294
Postoperative wound dehiscence rate1.69Same as national239
Abdominopelvic accidental puncture or laceration rate0.90Same as national923
CMS Medicare PSI 90: Patient safety and adverse events composite1.04Same 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 patients-10.7Not available144
Hospital return days for heart failure patients-10Not available417
Hospital return days for pneumonia patients-18.6Not available376
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)15.2Same as national1980
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)13.8Same as national251
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 surgery0.9Same as national506
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate13.2Same as national144
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients18.3Same as national110
Heart failure (HF) 30-Day Readmission Rate20.5Same as national417
Rate of readmission after hip/knee replacement5.8Same as national42
Pneumonia (PN) 30-Day Readmission Rate15.6Same as national376

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 rating41835
Doctor communication - star rating31835
Communication about medicines - star rating31835
Discharge information - star rating41835
Cleanliness - star rating41835
Quietness - star rating41835
Overall hospital rating - star rating41835
Recommend hospital - star rating51835
Summary star rating41835

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 volumehigh
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 Hypoglycemia
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination562914
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 better158417
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 better153393
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 better34020
Left before being seen058278
Head CT results
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients10045
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing214266
Appropriate care for severe sepsis and septic shock70688
Septic Shock 3-Hour Bundle63182
Septic Shock 6-Hour Bundle8799
Severe Sepsis 3-Hour Bundle86688
Severe Sepsis 6-Hour Bundle98381
Discharged on Antithrombotic Therapy99159
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 2
Venous Thromboembolism Prophylaxis997295
Intensive Care Unit Venous Thromboembolism Prophylaxis1001263

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 Wesley Chapel rated?
Adventhealth Wesley Chapel has a 5 out of 5 CMS overall star rating as of the latest CMS release.
Does Adventhealth Wesley Chapel have emergency services?
Yes. Adventhealth Wesley Chapel operates a 24/7 emergency department.
Where is Adventhealth Wesley Chapel located?
Adventhealth Wesley Chapel is located at 2600 Bruce B Downs Blvd, Wesley Chapel, FL 33544.
What type of hospital is Adventhealth Wesley Chapel?
Adventhealth Wesley Chapel is classified by CMS as a Acute Care Hospitals facility (Voluntary non-profit - Private).

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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