JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Proprietary

Roxborough Memorial Hospital

2 / 5

At a glance

Roxborough Memorial Hospital carries a 2-star CMS overall rating — below 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 Days1026Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases0.731Not 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 Limit0.326Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit6.422Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days1455Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases1.029Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases2Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)1.944Same as national
SSI - Colon Surgery: Lower Confidence LimitNot available
SSI - Colon Surgery: Upper Confidence LimitNot available
SSI - Colon Surgery: Number of Procedures4Not available
SSI - Colon Surgery: Predicted Cases0.136Not available
SSI - Colon Surgery: Observed Cases0Not available
SSI - Colon SurgeryNot available
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of ProceduresNot available
SSI - Abdominal Hysterectomy: Predicted CasesNot available
SSI - Abdominal Hysterectomy: Observed CasesNot available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitNot available
MRSA Bacteremia: Upper Confidence LimitNot available
MRSA Bacteremia: Patient Days12244Not available
MRSA Bacteremia: Predicted Cases0.656Not available
MRSA Bacteremia: Observed Cases0Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence Limit0.301Same as national
Clostridium Difficile (C.Diff): Upper Confidence Limit1.820Same as national
Clostridium Difficile (C.Diff): Patient Days12244Same as national
Clostridium Difficile (C.Diff): Predicted Cases6.091Same as national
Clostridium Difficile (C.Diff): Observed Cases5Same as national
Clostridium Difficile (C.Diff)0.821Same 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 Rate4.6Same as national215
Death rate for heart attack patientsNot available
Death rate for CABG surgery patientsNot available
Death rate for COPD patientsNot available
Death rate for heart failure patients8.3Same as national61
Death rate for pneumonia patients15.5Same as national85
Death rate for stroke patientsNot available
Pressure ulcer rate0.32Same as national715
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.20Same as national973
In-hospital fall-associated fracture rate0.26Same as national995
Postoperative hemorrhage or hematoma rate2.27Same as national88
Postoperative acute kidney injury requiring dialysis rateNot available
Postoperative respiratory failure rateNot available
Perioperative pulmonary embolism or deep vein thrombosis rate3.30Same as national89
Postoperative sepsis rateNot available
Postoperative wound dehiscence rateNot available
Abdominopelvic accidental puncture or laceration rate1.04Same as national59
CMS Medicare PSI 90: Patient safety and adverse events composite0.93Same 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 patients41.4Not available70
Hospital return days for pneumonia patients-13.2Not available81
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)15.5Same as national306
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)12.5Same as national112
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 surgeryNot available
Acute Myocardial Infarction (AMI) 30-Day Readmission RateNot available
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patientsNot available
Heart failure (HF) 30-Day Readmission Rate19.7Same as national70
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate15.4Same as national81

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 rating2460
Doctor communication - star rating2460
Communication about medicines - star rating1460
Discharge information - star rating1460
Cleanliness - star rating2460
Quietness - star rating2460
Overall hospital rating - star rating2460
Recommend hospital - star rating2460
Summary star rating2460

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 Hyperglycemia124894
Hospital Harm - Severe Hypoglycemia1959
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination981100
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 better186435
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 better182418
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better49016
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 seen322735
Head CT results
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing10556
Appropriate care for severe sepsis and septic shock5768
Septic Shock 3-Hour Bundle4418
Septic Shock 6-Hour Bundle
Severe Sepsis 3-Hour Bundle7568
Severe Sepsis 6-Hour Bundle9730
Discharged on Antithrombotic Therapy
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 29841
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 Roxborough Memorial Hospital rated?
Roxborough Memorial Hospital has a 2 out of 5 CMS overall star rating as of the latest CMS release.
Does Roxborough Memorial Hospital have emergency services?
Yes. Roxborough Memorial Hospital operates a 24/7 emergency department.
Where is Roxborough Memorial Hospital located?
Roxborough Memorial Hospital is located at 5800 Ridge Ave, Philadelphia, PA 19128.
What type of hospital is Roxborough Memorial Hospital?
Roxborough Memorial Hospital is classified by CMS as a Acute Care Hospitals facility (Proprietary).

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.

Report an issue with this page