JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Fhn Memorial Hospital

3 / 5

At a glance

Fhn 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 LimitNot available
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence LimitNot available
Central Line Associated Bloodstream Infection: Number of Device Days1425Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases0.972Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases0Not available
Central Line Associated Bloodstream Infection (ICU + select Wards)Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence LimitSame as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit1.342Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days3310Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases2.232Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases0Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.000Same as national
SSI - Colon Surgery: Lower Confidence LimitNot available
SSI - Colon Surgery: Upper Confidence LimitNot available
SSI - Colon Surgery: Number of Procedures30Not available
SSI - Colon Surgery: Predicted Cases0.711Not 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 Procedures52Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.490Not 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 Days21127Not available
MRSA Bacteremia: Predicted Cases0.801Not available
MRSA Bacteremia: Observed Cases0Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence Limit0.379Same as national
Clostridium Difficile (C.Diff): Upper Confidence Limit1.549Same as national
Clostridium Difficile (C.Diff): Patient Days20673Same as national
Clostridium Difficile (C.Diff): Predicted Cases9.807Same as national
Clostridium Difficile (C.Diff): Observed Cases8Same as national
Clostridium Difficile (C.Diff)0.816Same 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 patientsNot available
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4.2Same as national426
Death rate for heart attack patients12.3Same as national38
Death rate for CABG surgery patientsNot available
Death rate for COPD patients10.8Same as national51
Death rate for heart failure patients13.6Same as national151
Death rate for pneumonia patients15.3Same as national175
Death rate for stroke patients13.2Same as national49
Pressure ulcer rate0.37Same as national1523
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.19Same as national1739
In-hospital fall-associated fracture rate0.26Same as national1738
Postoperative hemorrhage or hematoma rate2.21Same as national279
Postoperative acute kidney injury requiring dialysis rate1.65Same as national75
Postoperative respiratory failure rate8.36Same as national77
Perioperative pulmonary embolism or deep vein thrombosis rate3.51Same as national289
Postoperative sepsis rate4.94Same as national66
Postoperative wound dehiscence rate1.70Same as national78
Abdominopelvic accidental puncture or laceration rate0.97Same as national251
CMS Medicare PSI 90: Patient safety and adverse events composite0.87Same 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-20.6Not available157
Hospital return days for pneumonia patients-8.7Not available180
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)15.3Same as national672
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)14.2Same as national482
Rate of inpatient admissions for patients receiving outpatient chemotherapy10.6Same as national44
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy5.4Same as national44
Ratio of unplanned hospital visits after hospital outpatient surgery1Same as national123
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate13.2Same as national35
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients18.2Same as national54
Heart failure (HF) 30-Day Readmission Rate17.9Same as national157
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate14.6Same as national180

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 rating5395
Doctor communication - star rating4395
Communication about medicines - star rating4395
Discharge information - star rating4395
Cleanliness - star rating3395
Quietness - star rating4395
Overall hospital rating - star rating4395
Recommend hospital - star rating3395
Summary star rating4395

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 Hypoglycemia0121
Hospital Harm - Opioid Related Adverse Events0181
Healthcare workers given influenza vaccination791440
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 better187483
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 better185463
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better32812
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 seen125556
Head CT results8918
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients10067
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing211049
Appropriate care for severe sepsis and septic shock63302
Septic Shock 3-Hour Bundle69115
Septic Shock 6-Hour Bundle8559
Severe Sepsis 3-Hour Bundle82302
Severe Sepsis 6-Hour Bundle94160
Discharged on Antithrombotic Therapy9358
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 29654
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 MeasureYes

Frequently asked questions

How is Fhn Memorial Hospital rated?
Fhn Memorial Hospital has a 3 out of 5 CMS overall star rating as of the latest CMS release.
Does Fhn Memorial Hospital have emergency services?
Yes. Fhn Memorial Hospital operates a 24/7 emergency department.
Where is Fhn Memorial Hospital located?
Fhn Memorial Hospital is located at 1045 West Stephenson Street, Freeport, IL 61032.
What type of hospital is Fhn Memorial Hospital?
Fhn 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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