Complications & Deaths Measures
20
CMS-tracked
Tennessee · Critical Access
Ascension Saint Thomas Three Rivers
Ascension Saint Thomas Three Rivers is a CMS-tracked critical access hospitals in Waverly, TN. CMS has not issued an overall star rating for this facility yet.
- 20
- Quality measures
- 6
- Infection types
Data currency: Hospital quality, safety, and patient-experience measures from the CMS Care Compare program (published quarterly), last refreshed May 2026. See our methodology for source dates. Spot a figure that looks wrong? Report a correction.
451 Highway 13 South, Waverly, TN 37185 · Humphreys County · (931) 296-4203
The verdict
Ascension Saint Thomas Three Rivers is Medicare-certified but has no CMS overall star rating yet, typically a sign its reporting volumes fell below CMS thresholds during the latest measurement window. 20 individual quality measures are still on file.
- 0
- measures better than national of 4 compared
- Yes
- emergency department on site
Type
Critical Access Hospitals
Ownership
Voluntary non-profit - Private
Emergency Services
Yes
Birthing Friendly
N/A
Patient Experience
17
HCAHPS domains
Infection Types
6
CDC NHSN
Worse-than-national profile for Ascension Saint Thomas Three Rivers
Mortality 2 measures
Safety of care 0 measures
Readmission 2 measures
Better than national Same as national Worse than national
Quality Measures
| Measure | Score | vs. National |
|---|---|---|
| Abdominopelvic accidental puncture or laceration rate | N/A | Not Available |
| CMS Medicare PSI 90: Patient safety and adverse events composite | N/A | Not Available |
| Death rate among surgical inpatients with serious treatable complications | N/A | Not Available |
| Death rate for CABG surgery patients | N/A | Not Available |
| Death rate for COPD patients | N/A | Number of Cases Too Small |
| Death rate for heart attack patients | N/A | Number of Cases Too Small |
| Death rate for heart failure patients | N/A | Number of Cases Too Small |
| Death rate for pneumonia patients | 24.5 | Worse than National |
| Death rate for stroke patients | N/A | Number of Cases Too Small |
| Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate | 5.2 | Same as National |
| Iatrogenic pneumothorax rate | N/A | Not Available |
| In-hospital fall-associated fracture rate | N/A | Not Available |
| Perioperative pulmonary embolism or deep vein thrombosis rate | N/A | Not Available |
| Postoperative acute kidney injury requiring dialysis rate | N/A | Not Available |
| Postoperative hemorrhage or hematoma rate | N/A | Not Available |
Patient Experience (HCAHPS)
| Survey Question | Star Rating |
|---|---|
| Cleanliness - linear mean score | N/A |
| Cleanliness - star rating | N/A |
| Communication about medicines - linear mean score | N/A |
| Communication about medicines - star rating | N/A |
| Discharge information - linear mean score | N/A |
| Discharge information - star rating | N/A |
| Doctor communication - linear mean score | N/A |
| Doctor communication - star rating | N/A |
| Nurse communication - linear mean score | N/A |
| Nurse communication - star rating | N/A |
| Overall hospital rating - linear mean score | N/A |
| Overall hospital rating - star rating | N/A |
| Quietness - linear mean score | N/A |
| Quietness - star rating | N/A |
| Recommend hospital - linear mean score | N/A |
| Recommend hospital - star rating | N/A |
| Summary star rating | N/A |
Safety & Infections
| Measure | Score | vs. National |
|---|---|---|
| Catheter Associated Urinary Tract Infections (ICU + select Wards) | N/A | Not Available |
| Central Line Associated Bloodstream Infection (ICU + select Wards) | N/A | Not Available |
| Clostridium Difficile (C.Diff) | N/A | Not Available |
| MRSA Bacteremia | N/A | Not Available |
| SSI - Abdominal Hysterectomy | N/A | Not Available |
| SSI - Colon Surgery | N/A | Not Available |
Staffing & Spending
Unplanned Visits & Readmissions
| Measure | Score | vs. National |
|---|---|---|
| Acute Myocardial Infarction (AMI) 30-Day Readmission Rate | N/A | Number of Cases Too Small |
| Heart failure (HF) 30-Day Readmission Rate | N/A | Number of Cases Too Small |
| Hospital return days for heart attack patients | N/A | Number of Cases Too Small |
| Hospital return days for heart failure patients | N/A | Number of Cases Too Small |
| Hospital return days for pneumonia patients | 11.8 | Average Days per 100 Discharges |
| Hybrid Hospital-Wide All-Cause Readmission Measure (HWR) | 15.6 | Same as National |
| Pneumonia (PN) 30-Day Readmission Rate | 16.2 | Same as National |
| Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy | N/A | Not Available |
| Rate of inpatient admissions for patients receiving outpatient chemotherapy | N/A | Not Available |
| Rate of readmission after hip/knee replacement | N/A | Not Available |
| Rate of readmission for CABG | N/A | Not Available |
| Rate of readmission for chronic obstructive pulmonary disease (COPD) patients | N/A | Number of Cases Too Small |
| Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies) | N/A | Number of Cases Too Small |
| Ratio of unplanned hospital visits after hospital outpatient surgery | N/A | Not Available |
Medicare Spending
| Measure | Score |
|---|---|
| Medicare hospital spending per patient (Medicare Spending per Beneficiary) | N/A |
Maternal Health
CMS maternal-care measures reported for this facility. The Hospital Compare maternal extract lists measure names and reporting windows; it does not publish numeric scores or sample sizes in the corpus we ingest, so those columns are omitted rather than filled with N/A.
| Measure |
|---|
| Cesarean Birth |
| Maternal Morbidity Structural Measure |
| Risk Adjusted Severe Obstetric Complications (All) |
| Risk Adjusted Severe Obstetric Complications (excluding blood-transfusion-only cases) |
Nationwide hospitals with similar CMS profiles
Peer sets for Ascension Saint Thomas Three Rivers outside Tennessee, keyed to the elevated worse-than-national share.
Similar mortality outcomes
Nearest mortality measures rated better than national, outside TN (0 better here).
Nearby Hospitals in Tennessee
Other Medicare-certified hospitals in Tennessee.
One of 121 Medicare-certified hospitals in Tennessee, 6 are shown here.
Affiliate of Vitruvian Health
Cleveland, TN
2/5
Acute Care Hospitals
Ascension Saint Thomas Behavioral Health Hospital
Nashville, TN
No rating Psychiatric
Ascension Saint Thomas Hospital
Nashville, TN
3/5
Acute Care Hospitals
Baptist Memorial Hospital
Memphis, TN
3/5
Acute Care Hospitals
Baptist Memorial Hospital - Carroll County
Huntingdon, TN
4/5
Acute Care Hospitals
Baptist Memorial Hospital Tipton
Covington, TN
3/5
Acute Care Hospitals
Compare Ascension Saint Thomas Three Rivers vs Affiliate of Vitruvian Health →
What to do with Ascension Saint Thomas Three Rivers
Use this page's CMS-sourced figures as a starting filter, not a final verdict.
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Frequently Asked Questions
How does Ascension Saint Thomas Three Rivers compare to other hospitals on CMS star rating?
Ascension Saint Thomas Three Rivers has no CMS overall star rating, so it is excluded from the rated-hospital corpus placement (unrated).
What is the CMS star rating for Ascension Saint Thomas Three Rivers?
Ascension Saint Thomas Three Rivers does not currently have a CMS star rating, typically because reporting volumes fell below CMS's calculation threshold.
How does Ascension Saint Thomas Three Rivers perform on quality measures?
1 of 4 compared measures rate worse than national at Ascension Saint Thomas Three Rivers (elevated worse-share tercile); 0 rate better (sparse).
What do patients say about Ascension Saint Thomas Three Rivers?
Ascension Saint Thomas Three Rivers reports 17 HCAHPS patient-experience domain scores.
What are the infection rates at Ascension Saint Thomas Three Rivers?
Ascension Saint Thomas Three Rivers tracks 6 healthcare-associated infection types (CDC NHSN). 0 are better than the national benchmark, 0 are worse, and 0 are at the national average.
Does Ascension Saint Thomas Three Rivers have emergency services?
Yes, Ascension Saint Thomas Three Rivers provides emergency services.
What type of hospital is Ascension Saint Thomas Three Rivers?
Ascension Saint Thomas Three Rivers is a Critical Access Hospitals facility with Voluntary non-profit - Private ownership, located in Waverly, TN.
How much does Medicare spend at Ascension Saint Thomas Three Rivers?
1 Medicare spending category is on file for Ascension Saint Thomas Three Rivers, per episode vs. the national median.
Does Ascension Saint Thomas Three Rivers offer maternal health services?
Yes, Ascension Saint Thomas Three Rivers reports 4 maternal health measures.