JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Community Memorial Hospital

4 / 5

At a glance

Community Memorial Hospital carries a 4-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 Limit1.039Same as national
Central Line Associated Bloodstream Infection: Number of Device Days3238Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases2.884Same 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 Limit0.012Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit1.175Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days4243Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases4.196Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases1Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.238Same as national
SSI - Colon Surgery: Lower Confidence Limit0.213Same as national
SSI - Colon Surgery: Upper Confidence Limit4.193Same as national
SSI - Colon Surgery: Number of Procedures60Same as national
SSI - Colon Surgery: Predicted Cases1.576Same as national
SSI - Colon Surgery: Observed Cases2Same as national
SSI - Colon Surgery1.269Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures38Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.323Not available
SSI - Abdominal Hysterectomy: Observed Cases2Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitSame as national
MRSA Bacteremia: Upper Confidence Limit1.653Same as national
MRSA Bacteremia: Patient Days41933Same as national
MRSA Bacteremia: Predicted Cases1.812Same as national
MRSA Bacteremia: Observed Cases0Same as national
MRSA Bacteremia0.000Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.105Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.635Better than national
Clostridium Difficile (C.Diff): Patient Days41933Better than national
Clostridium Difficile (C.Diff): Predicted Cases17.457Better than national
Clostridium Difficile (C.Diff): Observed Cases5Better than national
Clostridium Difficile (C.Diff)0.286Better 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 national63
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate3.9Same as national938
Death rate for heart attack patients11.6Same as national76
Death rate for CABG surgery patientsNot available
Death rate for COPD patients7Same as national102
Death rate for heart failure patients12.3Same as national353
Death rate for pneumonia patients15Same as national230
Death rate for stroke patients14.4Same as national123
Pressure ulcer rate0.22Same as national3089
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.17Same as national3859
In-hospital fall-associated fracture rate0.27Same as national3801
Postoperative hemorrhage or hematoma rate2.34Same as national673
Postoperative acute kidney injury requiring dialysis rate1.66Same as national66
Postoperative respiratory failure rate8.81Same as national66
Perioperative pulmonary embolism or deep vein thrombosis rate3.24Same as national746
Postoperative sepsis rate5.15Same as national59
Postoperative wound dehiscence rate1.72Same as national139
Abdominopelvic accidental puncture or laceration rate1.22Same as national619
CMS Medicare PSI 90: Patient safety and adverse events composite0.85Same 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-43.8Not available59
Hospital return days for heart failure patients46.8Not available380
Hospital return days for pneumonia patients-11.3Not available241
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.6Same as national1499
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)15Same as national465
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 national567
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate13.2Same as national59
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients18.3Same as national111
Heart failure (HF) 30-Day Readmission Rate22.1Same as national380
Rate of readmission after hip/knee replacement5.5Same as national64
Pneumonia (PN) 30-Day Readmission Rate15.9Same as national241

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 rating4686
Doctor communication - star rating4686
Communication about medicines - star rating3686
Discharge information - star rating4686
Cleanliness - star rating2686
Quietness - star rating2686
Overall hospital rating - star rating4686
Recommend hospital - star rating4686
Summary star rating4686

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 Hypoglycemia12272
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination925261
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 better219405
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 better217386
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 better39413
Left before being seen229770
Head CT results8025
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients10079
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing132203
Appropriate care for severe sepsis and septic shock57145
Septic Shock 3-Hour Bundle6237
Septic Shock 6-Hour Bundle8020
Severe Sepsis 3-Hour Bundle74146
Severe Sepsis 6-Hour Bundle9383
Discharged on Antithrombotic Therapy99195
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 2
Venous Thromboembolism Prophylaxis864924
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 Community Memorial Hospital rated?
Community Memorial Hospital has a 4 out of 5 CMS overall star rating as of the latest CMS release.
Does Community Memorial Hospital have emergency services?
Yes. Community Memorial Hospital operates a 24/7 emergency department.
Where is Community Memorial Hospital located?
Community Memorial Hospital is located at W180 N8085 Town Hall Rd, Menomonee Falls, WI 53051.
What type of hospital is Community Memorial Hospital?
Community Memorial Hospital 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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