JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Cape Fear Valley Medical Center

2 / 5

At a glance

Cape Fear Valley Medical Center carries a 2-star CMS overall rating — below the national norm. On healthcare-associated infection measures, it performs better than the national average on 12 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 Limit0.666Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit1.688Same as national
Central Line Associated Bloodstream Infection: Number of Device Days15053Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases16.526Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases18Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)1.089Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.390Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit1.290Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days11625Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases14.826Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases11Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.742Same as national
SSI - Colon Surgery: Lower Confidence Limit0.724Same as national
SSI - Colon Surgery: Upper Confidence Limit2.541Same as national
SSI - Colon Surgery: Number of Procedures250Same as national
SSI - Colon Surgery: Predicted Cases7.015Same as national
SSI - Colon Surgery: Observed Cases10Same as national
SSI - Colon Surgery1.426Same as national
SSI - Abdominal Hysterectomy: Lower Confidence Limit0.688Same as national
SSI - Abdominal Hysterectomy: Upper Confidence Limit4.165Same as national
SSI - Abdominal Hysterectomy: Number of Procedures275Same as national
SSI - Abdominal Hysterectomy: Predicted Cases2.661Same as national
SSI - Abdominal Hysterectomy: Observed Cases5Same as national
SSI - Abdominal Hysterectomy1.879Same as national
MRSA Bacteremia: Lower Confidence Limit0.228Better than national
MRSA Bacteremia: Upper Confidence Limit0.934Better than national
MRSA Bacteremia: Patient Days193676Better than national
MRSA Bacteremia: Predicted Cases16.273Better than national
MRSA Bacteremia: Observed Cases8Better than national
MRSA Bacteremia0.492Better than national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.468Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.798Better than national
Clostridium Difficile (C.Diff): Patient Days174290Better than national
Clostridium Difficile (C.Diff): Predicted Cases87.616Better than national
Clostridium Difficile (C.Diff): Observed Cases54Better than national
Clostridium Difficile (C.Diff)0.616Better 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 patients3.5Same as national28
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4.2Same as national2228
Death rate for heart attack patients13.7Same as national270
Death rate for CABG surgery patients2.4Same as national86
Death rate for COPD patients8.9Same as national267
Death rate for heart failure patients9.9Same as national603
Death rate for pneumonia patients21.6Worse than national625
Death rate for stroke patients11.6Same as national351
Pressure ulcer rate1.09Same as national8747
Death rate among surgical inpatients with serious treatable complications201.86Same as national105
Iatrogenic pneumothorax rate0.18Same as national10317
In-hospital fall-associated fracture rate0.22Same as national10531
Postoperative hemorrhage or hematoma rate1.94Same as national1795
Postoperative acute kidney injury requiring dialysis rate1.37Same as national502
Postoperative respiratory failure rate7.48Same as national530
Perioperative pulmonary embolism or deep vein thrombosis rate3.40Same as national1912
Postoperative sepsis rate5.28Same as national477
Postoperative wound dehiscence rate1.82Same as national369
Abdominopelvic accidental puncture or laceration rate1.52Same as national1776
CMS Medicare PSI 90: Patient safety and adverse events composite1.06Same 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 patients8.8Not available252
Hospital return days for heart failure patients12Not available730
Hospital return days for pneumonia patients46Not available619
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)15.4Same as national3688
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)14.2Same as national209
Rate of inpatient admissions for patients receiving outpatient chemotherapy12.2Same as national301
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy5.8Same as national301
Ratio of unplanned hospital visits after hospital outpatient surgery1.1Same as national372
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate13.7Same as national252
Rate of readmission for CABG10.2Same as national84
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients18.8Same as national295
Heart failure (HF) 30-Day Readmission Rate21.1Same as national730
Rate of readmission after hip/knee replacement4.4Same as national25
Pneumonia (PN) 30-Day Readmission Rate17.7Same as national619

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 rating32799
Doctor communication - star rating32799
Communication about medicines - star rating32799
Discharge information - star rating32799
Cleanliness - star rating32799
Quietness - star rating32799
Overall hospital rating - star rating22799
Recommend hospital - star rating22799
Summary star rating32799

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 Hypoglycemia
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination966687
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 better232394
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 better219360
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better67431
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 seen190270
Head CT results5540
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients9628
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)78192
Safe Use of Opioids - Concurrent Prescribing139483
Appropriate care for severe sepsis and septic shock5096
Septic Shock 3-Hour Bundle7823
Septic Shock 6-Hour Bundle8513
Severe Sepsis 3-Hour Bundle6297
Severe Sepsis 6-Hour Bundle9030
Discharged on Antithrombotic Therapy96535
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 291523
Venous Thromboembolism Prophylaxis
Intensive Care Unit Venous Thromboembolism Prophylaxis982194

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 Cape Fear Valley Medical Center rated?
Cape Fear Valley Medical Center has a 2 out of 5 CMS overall star rating as of the latest CMS release.
Does Cape Fear Valley Medical Center have emergency services?
Yes. Cape Fear Valley Medical Center operates a 24/7 emergency department.
Where is Cape Fear Valley Medical Center located?
Cape Fear Valley Medical Center is located at 1638 Owen Drive P O Box 2000, Fayetteville, NC 28302.
What type of hospital is Cape Fear Valley Medical Center?
Cape Fear Valley Medical Center 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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