JCIPatientSafety.orgHospital Quality Directory

Critical Access Hospitals · Voluntary non-profit - Private

Shenandoah Memorial Hospital

3 / 5

At a glance

Shenandoah 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 Limit—Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit—Not available
Central Line Associated Bloodstream Infection: Number of Device Days204Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases0.055Not 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 Limit—Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit—Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days726Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases0.474Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases0Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards)—Not available
SSI - Colon Surgery: Lower Confidence Limit—Not available
SSI - Colon Surgery: Upper Confidence Limit—Not available
SSI - Colon Surgery: Number of Procedures2Not available
SSI - Colon Surgery: Predicted Cases0.052Not available
SSI - Colon Surgery: Observed Cases0Not available
SSI - Colon Surgery—Not available
SSI - Abdominal Hysterectomy: Lower Confidence Limit—Not available
SSI - Abdominal Hysterectomy: Upper Confidence Limit—Not available
SSI - Abdominal Hysterectomy: Number of Procedures2Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.020Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal Hysterectomy—Not available
MRSA Bacteremia: Lower Confidence Limit—Not available
MRSA Bacteremia: Upper Confidence Limit—Not available
MRSA Bacteremia: Patient Days7174Not available
MRSA Bacteremia: Predicted Cases0.149Not available
MRSA Bacteremia: Observed Cases0Not available
MRSA Bacteremia—Not available
Clostridium Difficile (C.Diff): Lower Confidence Limit0.025Same as national
Clostridium Difficile (C.Diff): Upper Confidence Limit2.425Same as national
Clostridium Difficile (C.Diff): Patient Days7174Same as national
Clostridium Difficile (C.Diff): Predicted Cases2.034Same as national
Clostridium Difficile (C.Diff): Observed Cases1Same as national
Clostridium Difficile (C.Diff)0.492Same 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 patients—Not available—
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate3.8Same as national298
Death rate for heart attack patients—Not available—
Death rate for CABG surgery patients—Not available—
Death rate for COPD patients9Same as national57
Death rate for heart failure patients14.2Same as national89
Death rate for pneumonia patients18Same as national111
Death rate for stroke patients—Not available—
Pressure ulcer rate—Not available—
Death rate among surgical inpatients with serious treatable complications—Not available—
Iatrogenic pneumothorax rate—Not available—
In-hospital fall-associated fracture rate—Not available—
Postoperative hemorrhage or hematoma rate—Not available—
Postoperative acute kidney injury requiring dialysis rate—Not available—
Postoperative respiratory failure rate—Not available—
Perioperative pulmonary embolism or deep vein thrombosis rate—Not available—
Postoperative sepsis rate—Not available—
Postoperative wound dehiscence rate—Not available—
Abdominopelvic accidental puncture or laceration rate—Not available—
CMS Medicare PSI 90: Patient safety and adverse events composite—Not available—

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—Not available—
Hospital return days for heart failure patients4.9Not available105
Hospital return days for pneumonia patients-19.7Not available129
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.6Same as national437
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)12.5Same as national385
Rate of inpatient admissions for patients receiving outpatient chemotherapy—Not available—
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy—Not available—
Ratio of unplanned hospital visits after hospital outpatient surgery1.1Same as national61
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate—Not available—
Rate of readmission for CABG—Not available—
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients17.7Same as national64
Heart failure (HF) 30-Day Readmission Rate20.5Same as national105
Rate of readmission after hip/knee replacement—Not available—
Pneumonia (PN) 30-Day Readmission Rate15.4Same as national129

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 rating5269
Doctor communication - star rating4269
Communication about medicines - star rating4269
Discharge information - star rating4269
Cleanliness - star rating4269
Quietness - star rating4269
Overall hospital rating - star rating4269
Recommend hospital - star rating4269
Summary star rating4269

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 Hyperglycemia191221
Hospital Harm - Severe Hypoglycemia0432
Hospital Harm - Opioid Related Adverse Events——
Healthcare workers given influenza vaccination78487
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 better140461
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 better136436
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 better37915
Left before being seen221449
Head CT results——
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients057
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery——
ST-Segment Elevation Myocardial Infarction (STEMI)——
Safe Use of Opioids - Concurrent Prescribing18344
Appropriate care for severe sepsis and septic shock4450
Septic Shock 3-Hour Bundle6020
Septic Shock 6-Hour Bundle——
Severe Sepsis 3-Hour Bundle7250
Severe Sepsis 6-Hour Bundle8025
Discharged on Antithrombotic Therapy——
Anticoagulation Therapy for Atrial Fibrillation/Flutter——
Antithrombotic Therapy by End of Hospital Day 2——
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 Shenandoah Memorial Hospital rated?
Shenandoah Memorial Hospital has a 3 out of 5 CMS overall star rating as of the latest CMS release.
Does Shenandoah Memorial Hospital have emergency services?
Yes. Shenandoah Memorial Hospital operates a 24/7 emergency department.
Where is Shenandoah Memorial Hospital located?
Shenandoah Memorial Hospital is located at 759 South Main Street, Woodstock, VA 22664.
What type of hospital is Shenandoah Memorial Hospital?
Shenandoah Memorial Hospital is classified by CMS as a Critical Access 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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