Critical Access Hospitals · Voluntary non-profit - Private
Thedacare Medical Center - Berlin Inc
- 225 Memorial Drive, Berlin, WI 54923
- (920) 361-1313
- Critical Access Hospitals
- Emergency services available 24/7
At a glance
Thedacare Medical Center - Berlin Inc 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.
| Measure | Score | Compared 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 Days | 177 | Not available |
| Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases | 0.049 | Not available |
| Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases | 0 | Not 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 Days | 357 | Not available |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases | 0.233 | Not available |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases | 0 | Not 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 Procedures | — | Not available |
| SSI - Colon Surgery: Predicted Cases | — | Not available |
| SSI - Colon Surgery: Observed Cases | — | Not 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 Procedures | — | Not available |
| SSI - Abdominal Hysterectomy: Predicted Cases | — | Not available |
| SSI - Abdominal Hysterectomy: Observed Cases | — | Not available |
| SSI - Abdominal Hysterectomy | — | Not available |
| MRSA Bacteremia: Lower Confidence Limit | — | Not available |
| MRSA Bacteremia: Upper Confidence Limit | — | Not available |
| MRSA Bacteremia: Patient Days | 2865 | Not available |
| MRSA Bacteremia: Predicted Cases | 0.060 | Not available |
| MRSA Bacteremia: Observed Cases | 0 | Not available |
| MRSA Bacteremia | — | Not available |
| Clostridium Difficile (C.Diff): Lower Confidence Limit | — | Not available |
| Clostridium Difficile (C.Diff): Upper Confidence Limit | — | Not available |
| Clostridium Difficile (C.Diff): Patient Days | 2717 | Not available |
| Clostridium Difficile (C.Diff): Predicted Cases | 0.659 | Not available |
| Clostridium Difficile (C.Diff): Observed Cases | 0 | Not available |
| Clostridium Difficile (C.Diff) | — | Not available |
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.
| Measure | Score | Compared to national | Sample |
|---|---|---|---|
| Rate of complications for hip/knee replacement patients | — | Not available | — |
| Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate | 4 | Same as national | 81 |
| Death rate for heart attack patients | — | Not available | — |
| Death rate for CABG surgery patients | — | Not available | — |
| Death rate for COPD patients | — | Not available | — |
| Death rate for heart failure patients | 14.4 | Same as national | 30 |
| Death rate for pneumonia patients | 18.5 | Same as national | 41 |
| 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.
| Measure | Score | Compared to national | Sample |
|---|---|---|---|
| Hospital return days for heart attack patients | — | Not available | — |
| Hospital return days for heart failure patients | -3 | Not available | 27 |
| Hospital return days for pneumonia patients | -33.7 | Not available | 52 |
| Hybrid Hospital-Wide All-Cause Readmission Measure (HWR) | 14.7 | Same as national | 116 |
| Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies) | 13.4 | Same as national | 299 |
| 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 surgery | 1 | Same as national | 62 |
| 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) patients | — | Not available | — |
| Heart failure (HF) 30-Day Readmission Rate | 19.3 | Same as national | 27 |
| Rate of readmission after hip/knee replacement | — | Not available | — |
| Pneumonia (PN) 30-Day Readmission Rate | 15.7 | Same as national | 52 |
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.
| Measure | Score | Sample |
|---|---|---|
| Nurse communication - star rating | 4 | 181 |
| Doctor communication - star rating | 4 | 181 |
| Communication about medicines - star rating | 4 | 181 |
| Discharge information - star rating | 5 | 181 |
| Cleanliness - star rating | 4 | 181 |
| Quietness - star rating | 2 | 181 |
| Overall hospital rating - star rating | 4 | 181 |
| Recommend hospital - star rating | 4 | 181 |
| Summary star rating | 4 | 181 |
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.
| Measure | Score | Sample |
|---|---|---|
| Emergency department volume | low | — |
| 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 | 8 | 586 |
| Hospital Harm - Severe Hypoglycemia | 1 | 197 |
| Hospital Harm - Opioid Related Adverse Events | 0 | 335 |
| Healthcare workers given influenza vaccination | 55 | 698 |
| 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 better | 114 | 406 |
| 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 better | 110 | 365 |
| Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better | 165 | 13 |
| Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better | 184 | 28 |
| Left before being seen | 1 | 8272 |
| 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 Prescribing | 11 | 141 |
| Appropriate care for severe sepsis and septic shock | — | — |
| Septic Shock 3-Hour Bundle | — | — |
| Septic Shock 6-Hour Bundle | — | — |
| Severe Sepsis 3-Hour Bundle | — | — |
| Severe Sepsis 6-Hour Bundle | — | — |
| Discharged on Antithrombotic Therapy | — | — |
| Anticoagulation Therapy for Atrial Fibrillation/Flutter | — | — |
| Antithrombotic Therapy by End of Hospital Day 2 | — | — |
| Venous Thromboembolism Prophylaxis | 92 | 307 |
| 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.
| Measure | Score | Sample |
|---|---|---|
| Cesarean Birth | — | — |
| Risk Adjusted Severe Obstetric Complications (All) | — | — |
| Risk Adjusted Severe Obstetric Complications (excluding blood-transfusion-only cases) | — | — |
| Maternal Morbidity Structural Measure | Yes | — |
Frequently asked questions
- How is Thedacare Medical Center - Berlin Inc rated?
- Thedacare Medical Center - Berlin Inc has a 3 out of 5 CMS overall star rating as of the latest CMS release.
- Does Thedacare Medical Center - Berlin Inc have emergency services?
- Yes. Thedacare Medical Center - Berlin Inc operates a 24/7 emergency department.
- Where is Thedacare Medical Center - Berlin Inc located?
- Thedacare Medical Center - Berlin Inc is located at 225 Memorial Drive, Berlin, WI 54923.
- What type of hospital is Thedacare Medical Center - Berlin Inc?
- Thedacare Medical Center - Berlin Inc is classified by CMS as a Critical Access Hospitals facility (Voluntary non-profit - Private).
Compare with nearby hospitals
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.