JCIPatientSafety.orgHospital Quality Directory

Critical Access Hospitals · Voluntary non-profit - Private

Tomah Memorial Hospital

5 / 5

At a glance

Tomah Memorial Hospital carries a 5-star CMS overall rating — above 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 Days240Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases0.064Not 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—Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit1.619Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days757Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases1.850Same 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 Limit—Not available
SSI - Colon Surgery: Upper Confidence Limit—Not available
SSI - Colon Surgery: Number of Procedures5Not available
SSI - Colon Surgery: Predicted Cases0.111Not 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 Procedures1Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.009Not 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 Days4031Not available
MRSA Bacteremia: Predicted Cases0.084Not available
MRSA Bacteremia: Observed Cases0Not available
MRSA Bacteremia—Not available
Clostridium Difficile (C.Diff): Lower Confidence Limit0.202Same as national
Clostridium Difficile (C.Diff): Upper Confidence Limit3.976Same as national
Clostridium Difficile (C.Diff): Patient Days3660Same as national
Clostridium Difficile (C.Diff): Predicted Cases1.662Same as national
Clostridium Difficile (C.Diff): Observed Cases2Same as national
Clostridium Difficile (C.Diff)1.203Same 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 Rate4Same as national141
Death rate for heart attack patients—Not available—
Death rate for CABG surgery patients—Not available—
Death rate for COPD patients8.4Same as national28
Death rate for heart failure patients12.2Same as national40
Death rate for pneumonia patients17.7Same as national46
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 patients-2.7Not available47
Hospital return days for pneumonia patients7.2Not available49
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.6Same as national229
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)13Same as national207
Rate of inpatient admissions for patients receiving outpatient chemotherapy10.8Same as national49
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy5.7Same as national49
Ratio of unplanned hospital visits after hospital outpatient surgery1.2Same as national81
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) patients18Same as national25
Heart failure (HF) 30-Day Readmission Rate19.7Same as national47
Rate of readmission after hip/knee replacement—Not available—
Pneumonia (PN) 30-Day Readmission Rate16.2Same as national49

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 rating5209
Doctor communication - star rating5209
Communication about medicines - star rating4209
Discharge information - star rating5209
Cleanliness - star rating5209
Quietness - star rating5209
Overall hospital rating - star rating5209
Recommend hospital - star rating5209
Summary star rating5209

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 volume——
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 Hyperglycemia12794
Hospital Harm - Severe Hypoglycemia0200
Hospital Harm - Opioid Related Adverse Events——
Healthcare workers given influenza vaccination92703
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 better111434
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 better106398
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better24016
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better24725
Left before being seen——
Head CT results6913
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 Prescribing13145
Appropriate care for severe sepsis and septic shock7679
Septic Shock 3-Hour Bundle9521
Septic Shock 6-Hour Bundle——
Severe Sepsis 3-Hour Bundle8079
Severe Sepsis 6-Hour Bundle9852
Discharged on Antithrombotic Therapy——
Anticoagulation Therapy for Atrial Fibrillation/Flutter——
Antithrombotic Therapy by End of Hospital Day 2——
Venous Thromboembolism Prophylaxis68529
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 Measure——

Frequently asked questions

How is Tomah Memorial Hospital rated?
Tomah Memorial Hospital has a 5 out of 5 CMS overall star rating as of the latest CMS release.
Does Tomah Memorial Hospital have emergency services?
Yes. Tomah Memorial Hospital operates a 24/7 emergency department.
Where is Tomah Memorial Hospital located?
Tomah Memorial Hospital is located at 501 Gopher Dr, Tomah, WI 54660.
What type of hospital is Tomah Memorial Hospital?
Tomah 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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