Acute Care Hospital

AdventHealth Fish Memorial

1055 Saxon Blvd, Orange City, FL 32763
24/7 Emergency Services
5 out of 5 Stars Why 5 stars? AdventHealth Fish Memorial's 5-star rating reflects above-average performance on Timely Care.

CMS Overall Hospital Quality Star Rating · AdventHealth Fish Memorial

How was AdventHealth Fish Memorial's 5-star rating calculated?

The CMS Overall Hospital Quality Star Rating applies to acute care hospitals like AdventHealth Fish Memorial. CMS standardizes every underlying measure against the national rate, computes a weighted score for each of five domains, sums them by the fixed weights below, and assigns 1–5 stars using k-means clustering across all reporting hospitals.

Domains that fed AdventHealth Fish Memorial's rating
Domain Weight Measures reported Hospital performance vs. national
Mortality 22% 6 of 7 1 better 5 same 0 worse
Safety of Care 22% 17 of 19 1 better 16 same 0 worse
Readmissions 22% 4 of 6 1 better 1 same 2 worse
Timely & Effective Care 12% 14 of 22 6 better 5 same 3 worse
Patient Experience 22% HCAHPS See HCAHPS detail below

How star meaning varies by hospital type. This CMS Overall Star Rating only applies to acute care hospitals. Children's hospitals (Pediatric Quality), psychiatric hospitals (IPFQR), inpatient rehabilitation facilities (IRF QRP), long-term acute care hospitals (LTACH QRP), and VA medical centers each use separate quality programs designed for their patient populations. Comparing star ratings across these facility types isn't meaningful — see the methodology page for the full mapping of which program applies to which facility.

How CareRanks computes ratings → · CMS official methodology ↗

Quality measures

Mortality

Same as National Average

Measures the rate at which patients die within 30 days of hospital admission for specific conditions. A lower mortality rate indicates better outcomes.

Underlying measures: Death rate for heart failure patients Better Than the National Rate Hospital score: 7.80 95% interval: 6.10 – 9.80 Sample size: 403 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_HF Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate No Different Than the National Rate Hospital score: 3.80 95% interval: 3.20 – 4.50 Sample size: 1,029 Reporting period: 07/01/2023 – 06/30/2024 CMS measure id: Hybrid_HWM Death rate for COPD patients No Different Than the National Rate Hospital score: 7.70 95% interval: 4.90 – 11.30 Sample size: 104 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_COPD Death rate for heart attack patients No Different Than the National Rate Hospital score: 10.90 95% interval: 8.40 – 13.60 Sample size: 127 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_AMI Death rate for pneumonia patients No Different Than the National Rate Hospital score: 15.10 95% interval: 12.80 – 17.90 Sample size: 410 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_PN Death rate for stroke patients No Different Than the National Rate Hospital score: 10.40 95% interval: 7.90 – 13.40 Sample size: 138 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_STK Death rate for CABG surgery patients Not Available Hospital score: — Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_CABG

Safety of Care

Same as National Average

Tracks hospital-acquired infections, surgical complications, and other patient safety indicators. Lower rates indicate better safety practices.

Underlying measures: Clostridium Difficile (C.Diff) Better than the National Benchmark Hospital score: 0.00 SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_6_SIR Abdominopelvic accidental puncture or laceration rate No Different Than the National Rate Hospital score: 0.85 95% interval: 0.00 – 1.83 Sample size: 785 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_15 Catheter Associated Urinary Tract Infections (ICU + select Wards) No Different than National Benchmark Hospital score: 0.26 SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_2_SIR Central Line Associated Bloodstream Infection (ICU + select Wards) No Different than National Benchmark Hospital score: 0.29 SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_1_SIR Iatrogenic pneumothorax rate No Different Than the National Rate Hospital score: 0.27 95% interval: 0.06 – 0.48 Sample size: 4,608 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_06 In-hospital fall-associated fracture rate No Different Than the National Rate Hospital score: 0.22 95% interval: 0.03 – 0.42 Sample size: 4,815 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_08 MRSA Bacteremia No Different than National Benchmark Hospital score: 0.40 SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_5_SIR Postoperative hemorrhage or hematoma rate No Different Than the National Rate Hospital score: 1.97 95% interval: 0.38 – 3.57 Sample size: 498 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_09 Perioperative pulmonary embolism or deep vein thrombosis rate No Different Than the National Rate Hospital score: 3.57 95% interval: 1.23 – 5.91 Sample size: 508 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_12 Postoperative acute kidney injury requiring dialysis rate No Different Than the National Rate Hospital score: 1.60 95% interval: 0.00 – 3.30 Sample size: 124 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_10 Postoperative respiratory failure rate No Different Than the National Rate Hospital score: 9.57 95% interval: 0.63 – 18.52 Sample size: 122 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_11 Postoperative sepsis rate No Different Than the National Rate Hospital score: 7.18 95% interval: 3.14 – 11.22 Sample size: 125 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_13 Pressure ulcer rate No Different Than the National Rate Hospital score: 0.36 95% interval: 0.00 – 1.05 Sample size: 3,940 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_03 CMS Medicare PSI 90: Patient safety and adverse events composite No Different Than the National Value Hospital score: 0.98 95% interval: 0.62 – 1.35 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_90 SSI - Colon Surgery No Different than National Benchmark Hospital score: 0.64 SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_3_SIR Death rate among surgical inpatients with serious treatable complications No Different Than the National Rate Hospital score: 138.87 95% interval: 80.32 – 197.42 Sample size: 31 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_04 Postoperative wound dehiscence rate No Different Than the National Rate Hospital score: 1.65 95% interval: 0.16 – 3.13 Sample size: 160 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_14 Rate of complications for hip/knee replacement patients Number of Cases Too Small Hospital score: — Reporting period: 04/01/2021 – 03/31/2024 CMS measure id: COMP_HIP_KNEE SSI - Abdominal Hysterectomy Not Available Hospital score: — SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_4_SIR

Readmissions

Same as National Average

Measures how often patients return to the hospital within 30 days of discharge. Lower readmission rates suggest effective treatment and discharge planning.

Underlying measures: 30-day Readmission, Pneumonia Better than expected Hospital score: 0.94 Sample size: 443 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-PN-HRRP 30-day Readmission, Heart Failure As expected Hospital score: 0.99 Sample size: 455 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-HF-HRRP 30-day Readmission, COPD Worse than expected Hospital score: 1.05 Sample size: 117 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-COPD-HRRP 30-day Readmission, Heart Attack Worse than expected Hospital score: 1.10 Sample size: 98 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-AMI-HRRP 30-day Readmission, Bypass Surgery Hospital score: — Sample size: 0 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-CABG-HRRP 30-day Readmission, Hip/Knee Replacement Hospital score: — Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-HIP-KNEE-HRRP

Patient Experience

Same as National Average

Based on the HCAHPS survey — patient satisfaction with communication, cleanliness, pain management, and discharge information.

Patient survey detail — the questions feeding the Patient Experience domain above expand ↓

CMS computes the Patient Experience domain from the federal HCAHPS survey. Each bar below is one survey question; the percentage is the share of AdventHealth's recent patients who gave the most positive response. HCAHPS percentages aren't directly comparable across all measures — see the methodology page for how CMS weights them.

  • Communication with Nurses 84%
  • Communication with Doctors 77%
  • Hospital Cleanliness 74%
  • Hospital Quietness 67%
  • Staff Responsiveness N/A
  • Discharge Information 89%
  • Overall Hospital Rating (9 or 10) 74%
  • Would Recommend Hospital 74%

Percentages represent patients who gave the most positive response. Survey conducted by CMS through the HCAHPS program.

Timely & Effective Care

Better than National Average

Measures how quickly the hospital provides important treatments such as antibiotics for pneumonia or interventions for heart attacks.

Underlying measures: Left before being seen Better than ~75% of hospitals Hospital score: 1.00 % National median: 1.00 % (lower is better) Sample size: 70,577 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: OP_22 Appropriate care for severe sepsis and septic shock Better than ~75% of hospitals Hospital score: 82.00 % National median: 64.00 % (higher is better) Sample size: 385 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: SEP_1 Septic Shock 3-Hour Bundle Better than ~75% of hospitals Hospital score: 86.00 % National median: 72.00 % (higher is better) Sample size: 132 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: SEP_SH_3HR Septic Shock 6-Hour Bundle Better than ~75% of hospitals Hospital score: 95.00 % National median: 89.00 % (higher is better) Sample size: 93 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: SEP_SH_6HR Severe Sepsis 3-Hour Bundle Better than ~75% of hospitals Hospital score: 90.00 % National median: 81.00 % (higher is better) Sample size: 387 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: SEV_SEP_3HR Severe Sepsis 6-Hour Bundle Better than ~75% of hospitals Hospital score: 99.00 % National median: 94.00 % (higher is better) Sample size: 237 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: SEV_SEP_6HR Safe Use of Opioids - Concurrent Prescribing Near the national median Hospital score: 16.00 % National median: 15.00 % (lower is better) Sample size: 3,045 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: SAFE_USE_OF_OPIOIDS 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 Near the national median Hospital score: 143.00 min National median: 148.00 min (lower is better) Sample size: 423 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: OP_18b 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 Near the national median Hospital score: 144.00 min National median: 154.00 min (lower is better) Sample size: 432 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: OP_18a Intensive Care Unit Venous Thromboembolism Prophylaxis Near the national median Hospital score: 98.00 % National median: 97.00 % (higher is better) Sample size: 2,011 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: VTE_2 Hospital Harm - Severe Hypoglycemia Near the national median Hospital score: 1.00 % National median: 1.00 % (lower is better) Sample size: 4,227 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: HH_HYPO Discharged on Antithrombotic Therapy Worse than ~75% of hospitals Hospital score: 96.00 % National median: 98.00 % (higher is better) Sample size: 251 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: STK_02 Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients Worse than ~75% of hospitals Hospital score: 78.00 % National median: 97.00 % (higher is better) Sample size: 27 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: OP_29 Healthcare workers given influenza vaccination Worse than ~75% of hospitals Hospital score: 55.00 % National median: 79.00 % (higher is better) Sample size: 1,799 Reporting period: 10/01/2024 – 03/31/2025 CMS measure id: IMM_3

Clinical Staff

AdventHealth Fish Memorial has 489 CMS-affiliated clinicians on its roster — physicians, advanced practice providers, and other Medicare-enrolled professionals who list this hospital as an affiliated facility.

Top specialties

  • Diagnostic Radiology 88
  • Internal Medicine 63
  • Nurse Practitioner 56
  • Family Practice 45
  • Physician Assistant 37
  • Neurology 19
  • Cardiovascular Disease (Cardiology) 16
  • Certified Registered Nurse Anesthetist (Crna) 15

Self-reported primary specialty in the CMS Doctors & Clinicians dataset. Many clinicians serve multiple facilities.

Practice characteristics

Accept Medicare assignment
483 (99%)

Bill Medicare directly at the approved rate — patients only owe co-insurance/deductible.

Offer telehealth
154 (31%)

Indicated by the clinician in their CMS profile as routinely providing virtual visits.

Medicare quality scoring (MIPS)

243 of these clinicians have a published Merit-based Incentive Payment System (MIPS) final score. Of those, 115 (47%) score above the national median of 85.5.

MIPS scoring is heavily compressed at the top of the 0–100 range, so individual scores are not a reliable consumer signal. We surface roster-level coverage and the share above the national median instead.

Source: CMS Doctors and Clinicians (Care Compare) national downloadable file and MIPS Performance Year final scores, as of 2026-05-27. Affiliations from the CMS Facility Affiliations dataset. About 16% of small facilities (critical access, rural emergency, freestanding psych, IRF/LTCH) do not appear in the affiliations file and therefore have no panel.

Find a Doctor

Search the 488 clinicians affiliated with AdventHealth Fish Memorial. Each name links to that clinician's official Medicare Care Compare profile, where you can see their credentials, secondary specialties, group affiliations, and (when applicable) MIPS quality scores.

Showing 30 of 488 clinicians (alphabetical)

Roster from CMS Doctors and Clinicians (Care Compare), updated 2026-05-27. A clinician may also practice at other facilities; "affiliated" means this hospital is on their CMS profile, not that they exclusively work here.

Pricing & Costs

Facility Information

Facility type
Acute Care Hospitals
Ownership
Voluntary non-profit - Church
Emergency services
Yes — 24/7

Nearby Hospitals

About this data

Quality and ratings data are sourced from the U.S. Centers for Medicare & Medicaid Services (CMS) Hospital Compare program. Star ratings are CMS's own calculation; CareRanks does not modify or re-weight them. Facility-level details (address, beds, ownership, teaching status) come from CMS provider files and the CMS Provider of Services file.

Pricing data, where shown, is drawn from the hospital's own Machine-Readable File (MRF) published under the federal Hospital Price Transparency Rule. See our methodology for the full update cadence and limitations.

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