JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Falmouth Hospital

4 / 5

At a glance

Falmouth 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 Limit1.226Same as national
Central Line Associated Bloodstream Infection: Number of Device Days3484Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases2.443Same 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 Limit0.027Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit2.657Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days3186Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases1.856Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases1Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.539Same as national
SSI - Colon Surgery: Lower Confidence Limit0.426Same as national
SSI - Colon Surgery: Upper Confidence Limit4.556Same as national
SSI - Colon Surgery: Number of Procedures73Same as national
SSI - Colon Surgery: Predicted Cases1.792Same as national
SSI - Colon Surgery: Observed Cases3Same as national
SSI - Colon Surgery1.674Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures17Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.132Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence Limit0.331Same as national
MRSA Bacteremia: Upper Confidence Limit6.523Same as national
MRSA Bacteremia: Patient Days24998Same as national
MRSA Bacteremia: Predicted Cases1.013Same as national
MRSA Bacteremia: Observed Cases2Same as national
MRSA Bacteremia1.974Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.072Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.770Better than national
Clostridium Difficile (C.Diff): Patient Days24998Better than national
Clostridium Difficile (C.Diff): Predicted Cases10.602Better than national
Clostridium Difficile (C.Diff): Observed Cases3Better than national
Clostridium Difficile (C.Diff)0.283Better 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 patients3.3Same as national160
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate3.9Same as national1596
Death rate for heart attack patients11.2Same as national134
Death rate for CABG surgery patientsNot available
Death rate for COPD patients6.9Same as national183
Death rate for heart failure patients9.8Same as national451
Death rate for pneumonia patients14.6Same as national747
Death rate for stroke patients11.1Same as national210
Pressure ulcer rate0.41Same as national4928
Death rate among surgical inpatients with serious treatable complications179.92Same as national38
Iatrogenic pneumothorax rate0.22Same as national5969
In-hospital fall-associated fracture rate0.22Same as national5962
Postoperative hemorrhage or hematoma rate2.94Same as national673
Postoperative acute kidney injury requiring dialysis rate2.08Same as national217
Postoperative respiratory failure rate13.94Same as national226
Perioperative pulmonary embolism or deep vein thrombosis rate4.76Same as national751
Postoperative sepsis rate6.46Same as national195
Postoperative wound dehiscence rate1.64Same as national182
Abdominopelvic accidental puncture or laceration rate1.17Same as national615
CMS Medicare PSI 90: Patient safety and adverse events composite1.17Same 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-13.4Not available70
Hospital return days for heart failure patients4.9Not available487
Hospital return days for pneumonia patients9.6Not available777
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)16Same as national2516
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)12.6Same as national2543
Rate of inpatient admissions for patients receiving outpatient chemotherapy9.9Same as national30
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy5.3Same as national30
Ratio of unplanned hospital visits after hospital outpatient surgery1.1Same as national618
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate13.5Same as national70
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients18.6Same as national202
Heart failure (HF) 30-Day Readmission Rate20.5Same as national487
Rate of readmission after hip/knee replacement4.4Same as national133
Pneumonia (PN) 30-Day Readmission Rate17Same as national777

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 rating4484
Doctor communication - star rating3484
Communication about medicines - star rating2484
Discharge information - star rating4484
Cleanliness - star rating4484
Quietness - star rating2484
Overall hospital rating - star rating3484
Recommend hospital - star rating4484
Summary star rating3484

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 vaccination821193
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 better167403
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 better160367
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better98023
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better29715
Left before being seen133435
Head CT results8419
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients9973
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing201017
Appropriate care for severe sepsis and septic shock85123
Septic Shock 3-Hour Bundle8527
Septic Shock 6-Hour Bundle9315
Severe Sepsis 3-Hour Bundle92123
Severe Sepsis 6-Hour Bundle9776
Discharged on Antithrombotic Therapy98148
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 296142
Venous Thromboembolism Prophylaxis
Intensive Care Unit Venous Thromboembolism Prophylaxis96425

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 Falmouth Hospital rated?
Falmouth Hospital has a 4 out of 5 CMS overall star rating as of the latest CMS release.
Does Falmouth Hospital have emergency services?
Yes. Falmouth Hospital operates a 24/7 emergency department.
Where is Falmouth Hospital located?
Falmouth Hospital is located at 67 & 100 Ter Heun Drive, Falmouth, MA 02540.
What type of hospital is Falmouth Hospital?
Falmouth 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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