JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Ty Cobb Regional Medical Center, Llc

3 / 5

At a glance

Ty Cobb Regional Medical Center, Llc 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 LimitNot available
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence LimitNot available
Central Line Associated Bloodstream Infection: Number of Device Days241Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases0.149Not 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 LimitNot available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence LimitNot available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days900Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases0.459Not 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 LimitNot available
SSI - Colon Surgery: Upper Confidence LimitNot available
SSI - Colon Surgery: Number of Procedures4Not available
SSI - Colon Surgery: Predicted Cases0.115Not 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 Procedures21Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.191Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitNot available
MRSA Bacteremia: Upper Confidence LimitNot available
MRSA Bacteremia: Patient Days7914Not available
MRSA Bacteremia: Predicted Cases0.325Not available
MRSA Bacteremia: Observed Cases1Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence Limit0.022Same as national
Clostridium Difficile (C.Diff): Upper Confidence Limit2.146Same as national
Clostridium Difficile (C.Diff): Patient Days7511Same as national
Clostridium Difficile (C.Diff): Predicted Cases2.298Same as national
Clostridium Difficile (C.Diff): Observed Cases1Same as national
Clostridium Difficile (C.Diff)0.435Same 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 Rate4.2Same as national224
Death rate for heart attack patientsNot available
Death rate for CABG surgery patientsNot available
Death rate for COPD patients8.2Same as national55
Death rate for heart failure patients12Same as national57
Death rate for pneumonia patients14.8Same as national141
Death rate for stroke patients13.3Same as national33
Pressure ulcer rate0.53Same as national613
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.21Same as national828
In-hospital fall-associated fracture rate0.31Same as national803
Postoperative hemorrhage or hematoma rate2.33Same as national41
Postoperative acute kidney injury requiring dialysis rateNot available
Postoperative respiratory failure rateNot available
Perioperative pulmonary embolism or deep vein thrombosis rate3.41Same as national48
Postoperative sepsis rateNot available
Postoperative wound dehiscence rateNot available
Abdominopelvic accidental puncture or laceration rate1.05Same as national31
CMS Medicare PSI 90: Patient safety and adverse events composite0.95Same 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 patients71.7Not available67
Hospital return days for pneumonia patients-20Not available138
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.7Same as national288
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)12.3Same as national233
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) patients17.4Same as national56
Heart failure (HF) 30-Day Readmission Rate20.7Same as national67
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate15.5Same as national138

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 rating3228
Doctor communication - star rating3228
Communication about medicines - star rating3228
Discharge information - star rating4228
Cleanliness - star rating5228
Quietness - star rating4228
Overall hospital rating - star rating3228
Recommend hospital - star rating3228
Summary star rating3228

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 Hyperglycemia
Hospital Harm - Severe Hypoglycemia
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination40493
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 better104408
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 better102392
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better16913
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 seen124311
Head CT results
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients9067
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing18482
Appropriate care for severe sepsis and septic shock8163
Septic Shock 3-Hour Bundle8324
Septic Shock 6-Hour Bundle8715
Severe Sepsis 3-Hour Bundle9063
Severe Sepsis 6-Hour Bundle10038
Discharged on Antithrombotic Therapy10040
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 29736
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 MeasureYes

Frequently asked questions

How is Ty Cobb Regional Medical Center, Llc rated?
Ty Cobb Regional Medical Center, Llc has a 3 out of 5 CMS overall star rating as of the latest CMS release.
Does Ty Cobb Regional Medical Center, Llc have emergency services?
Yes. Ty Cobb Regional Medical Center, Llc operates a 24/7 emergency department.
Where is Ty Cobb Regional Medical Center, Llc located?
Ty Cobb Regional Medical Center, Llc is located at 367 Clear Creek Parkway, Lavonia, GA 30553.
What type of hospital is Ty Cobb Regional Medical Center, Llc?
Ty Cobb Regional Medical Center, Llc is classified by CMS as a Acute Care 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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