JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Other

Caldwell Memorial Hospital

3 / 5

At a glance

Caldwell Memorial Hospital carries a 3-star CMS overall rating — in line with the national norm.

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 Limit0.457Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit4.889Same as national
Central Line Associated Bloodstream Infection: Number of Device Days2464Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases1.670Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases3Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)1.796Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.154Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit3.028Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days3161Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases2.182Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases2Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.917Same as national
SSI - Colon Surgery: Lower Confidence LimitNot available
SSI - Colon Surgery: Upper Confidence LimitNot available
SSI - Colon Surgery: Number of Procedures35Not available
SSI - Colon Surgery: Predicted Cases0.907Not available
SSI - Colon Surgery: Observed Cases1Not available
SSI - Colon SurgeryNot available
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures3Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.028Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitNot available
MRSA Bacteremia: Upper Confidence LimitNot available
MRSA Bacteremia: Patient Days20168Not available
MRSA Bacteremia: Predicted Cases0.860Not available
MRSA Bacteremia: Observed Cases1Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence Limit0.150Same as national
Clostridium Difficile (C.Diff): Upper Confidence Limit1.137Same as national
Clostridium Difficile (C.Diff): Patient Days20168Same as national
Clostridium Difficile (C.Diff): Predicted Cases8.487Same as national
Clostridium Difficile (C.Diff): Observed Cases4Same as national
Clostridium Difficile (C.Diff)0.471Same as 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 patients3.1Same as national77
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4.4Same as national412
Death rate for heart attack patients12.2Same as national54
Death rate for CABG surgery patientsNot available
Death rate for COPD patients11.6Same as national42
Death rate for heart failure patients13.9Same as national87
Death rate for pneumonia patients18Same as national150
Death rate for stroke patients13.2Same as national39
Pressure ulcer rate0.78Same as national1533
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.20Same as national1719
In-hospital fall-associated fracture rate0.25Same as national1682
Postoperative hemorrhage or hematoma rate3.10Same as national350
Postoperative acute kidney injury requiring dialysis rate1.62Same as national137
Postoperative respiratory failure rate9.57Same as national138
Perioperative pulmonary embolism or deep vein thrombosis rate4.39Same as national373
Postoperative sepsis rate5.00Same as national123
Postoperative wound dehiscence rate1.73Same as national46
Abdominopelvic accidental puncture or laceration rate1.02Same as national170
CMS Medicare PSI 90: Patient safety and adverse events composite1.08Same 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 patientsNot available
Hospital return days for heart failure patients-28.1Not available98
Hospital return days for pneumonia patients5Not available143
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.3Same as national605
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)15.9Same as national230
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 national271
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate14.1Same as national41
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients17.8Same as national48
Heart failure (HF) 30-Day Readmission Rate18.9Same as national98
Rate of readmission after hip/knee replacement5.7Same as national77
Pneumonia (PN) 30-Day Readmission Rate15.5Same as national143

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 rating3490
Doctor communication - star rating3490
Communication about medicines - star rating2490
Discharge information - star rating3490
Cleanliness - star rating3490
Quietness - star rating2490
Overall hospital rating - star rating3490
Recommend hospital - star rating2490
Summary star rating3490

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 volumemedium
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 vaccination901599
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 better192396
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 better189363
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better18919
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better41414
Left before being seen227222
Head CT results
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients72123
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing201129
Appropriate care for severe sepsis and septic shock76359
Septic Shock 3-Hour Bundle84159
Septic Shock 6-Hour Bundle8890
Severe Sepsis 3-Hour Bundle89361
Severe Sepsis 6-Hour Bundle98226
Discharged on Antithrombotic Therapy9560
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 29356
Venous Thromboembolism Prophylaxis
Intensive Care Unit Venous Thromboembolism Prophylaxis

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 MeasureNot Applicable (our hospital does not provide inpatient labor/delivery care)

Frequently asked questions

How is Caldwell Memorial Hospital rated?
Caldwell Memorial Hospital has a 3 out of 5 CMS overall star rating as of the latest CMS release.
Does Caldwell Memorial Hospital have emergency services?
Yes. Caldwell Memorial Hospital operates a 24/7 emergency department.
Where is Caldwell Memorial Hospital located?
Caldwell Memorial Hospital is located at 321 Mulberry St Sw, Lenoir, NC 28645.
What type of hospital is Caldwell Memorial Hospital?
Caldwell Memorial Hospital is classified by CMS as a Acute Care Hospitals facility (Voluntary non-profit - Other).

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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