JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Proprietary

Tristar Hendersonville Medical Center

4 / 5

At a glance

Tristar Hendersonville Medical Center carries a 4-star CMS overall rating — above the national norm. On healthcare-associated infection measures, it performs better than the national average on 6 and worse on 0.

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 LimitSame as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit1.869Same as national
Central Line Associated Bloodstream Infection: Number of Device Days2312Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases1.603Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases0Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.000Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence LimitSame as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit1.909Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days2326Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases1.569Same 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 Limit0.026Same as national
SSI - Colon Surgery: Upper Confidence Limit2.575Same as national
SSI - Colon Surgery: Number of Procedures78Same as national
SSI - Colon Surgery: Predicted Cases1.915Same as national
SSI - Colon Surgery: Observed Cases1Same as national
SSI - Colon Surgery0.522Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures24Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.244Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitSame as national
MRSA Bacteremia: Upper Confidence Limit2.418Same as national
MRSA Bacteremia: Patient Days33500Same as national
MRSA Bacteremia: Predicted Cases1.239Same as national
MRSA Bacteremia: Observed Cases0Same as national
MRSA Bacteremia0.000Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.003Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.296Better than national
Clostridium Difficile (C.Diff): Patient Days30181Better than national
Clostridium Difficile (C.Diff): Predicted Cases16.654Better than national
Clostridium Difficile (C.Diff): Observed Cases1Better than national
Clostridium Difficile (C.Diff)0.060Better than 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 patients4.5Same as national40
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate3.6Same as national838
Death rate for heart attack patients13.2Same as national104
Death rate for CABG surgery patientsNot available
Death rate for COPD patients7.4Same as national58
Death rate for heart failure patients10.6Same as national192
Death rate for pneumonia patients15.5Same as national354
Death rate for stroke patients12.1Same as national67
Pressure ulcer rate0.30Same as national2511
Death rate among surgical inpatients with serious treatable complications147.78Same as national46
Iatrogenic pneumothorax rate0.24Same as national3339
In-hospital fall-associated fracture rate0.28Same as national3341
Postoperative hemorrhage or hematoma rate2.05Same as national547
Postoperative acute kidney injury requiring dialysis rate1.60Same as national215
Postoperative respiratory failure rate6.95Same as national236
Perioperative pulmonary embolism or deep vein thrombosis rate2.76Same as national586
Postoperative sepsis rate6.26Same as national205
Postoperative wound dehiscence rate1.67Same as national173
Abdominopelvic accidental puncture or laceration rate0.93Same as national674
CMS Medicare PSI 90: Patient safety and adverse events composite0.84Same 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 patients-22.1Not available79
Hospital return days for heart failure patients10Not available204
Hospital return days for pneumonia patients-6.7Not available373
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)15.6Same as national1319
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)13.6Same as national971
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 surgery1.2Same as national280
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate13.5Same as national79
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients17.7Same as national62
Heart failure (HF) 30-Day Readmission Rate20.9Same as national204
Rate of readmission after hip/knee replacement5.1Same as national42
Pneumonia (PN) 30-Day Readmission Rate15.3Same as national373

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 rating2627
Doctor communication - star rating3627
Communication about medicines - star rating2627
Discharge information - star rating2627
Cleanliness - star rating3627
Quietness - star rating3627
Overall hospital rating - star rating3627
Recommend hospital - star rating3627
Summary star rating3627

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 volumehigh
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 Hypoglycemia
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination451531
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 better163448
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 better156414
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better50121
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better26014
Left before being seen150535
Head CT results5522
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients92104
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing173029
Appropriate care for severe sepsis and septic shock65121
Septic Shock 3-Hour Bundle5330
Septic Shock 6-Hour Bundle8015
Severe Sepsis 3-Hour Bundle85121
Severe Sepsis 6-Hour Bundle9277
Discharged on Antithrombotic Therapy
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 29579
Venous Thromboembolism Prophylaxis844054
Intensive Care Unit Venous Thromboembolism Prophylaxis991152

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 Tristar Hendersonville Medical Center rated?
Tristar Hendersonville Medical Center has a 4 out of 5 CMS overall star rating as of the latest CMS release.
Does Tristar Hendersonville Medical Center have emergency services?
Yes. Tristar Hendersonville Medical Center operates a 24/7 emergency department.
Where is Tristar Hendersonville Medical Center located?
Tristar Hendersonville Medical Center is located at 355 New Shackle Island Rd, Hendersonville, TN 37075.
What type of hospital is Tristar Hendersonville Medical Center?
Tristar Hendersonville Medical Center 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.

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