CMS certification 100134
Ed Fraser Memorial Hospital
159 N 3rd St, Macclenny, FL 32063
Ed Fraser Memorial Hospital has a CMS overall rating of 1 out of 5 stars. 75% of patients who answered CMS's national survey would definitely recommend it, against a US average of 71%. Of the 7 death, complication, infection and readmission measures CMS could compare, it does better than the nation on none and worse on 1. Emergency patients spend a median of 2 h 36 min in its emergency department before leaving (US median 2 h 42 min).
Every figure on this page is published by CMS; we arrange and explain it, and score nothing ourselves.
What patients said
Answers from patients who stayed here, collected by CMS in the national HCAHPS survey: 63 completed surveys, 22% response rate, Oct 2024 – Sep 2025.
Emergency department
How long emergency patients spent here and how some time-critical care went, from CMS's timely and effective care measures, Oct 2024 – Sep 2025. CMS classes this emergency department's patient volume as low; busier departments tend to have longer times, so the national median for departments of the same volume is shown too. These are medians over a year of visits, not a live wait time.
| Measure | This hospital | FL | US |
|---|---|---|---|
| Median time in the emergency department before leaving Lower is better · 360 visits sampled · US median for EDs of the same volume: 2 h 3 min | 2 h 36 min | 2 h 36 min | 2 h 42 min |
| Median time for psychiatric and mental health patients Lower is better · 16 visits sampled | 2 h 52 min | 3 h 40 min | 4 h 17 min |
| Left before being seen Lower is better · 12,253 patients | 2% | 1% | 2% |
| Stroke symptoms: brain scan read within 45 minutes Higher is better · 11 patients | 45% | 73% | 69% |
| Severe sepsis and septic shock: all recommended care given Higher is better · 21 patients | 81% | 73% | 65% |
How Ed Fraser Memorial Hospital compares with nearby hospitals
The closest hospitals of the same kind that CMS rates or surveys - the same city first, then the same county and ZIP area. Every figure is CMS's: the overall star rating, the share of patients who would definitely recommend the hospital, the median time emergency patients spent before leaving, and how many death, complication, infection and readmission measures CMS found better or worse than the national rate.
| Hospital | CMS stars | Would recommend | ER median time | Vs the nation |
|---|---|---|---|---|
| Ed Fraser Memorial HospitalThis hospital | 1/5 | 75% | 2 h 36 min | 1 worse |
| Ascension St Vincent's Clay CountySame ZIP area · Middleburg | 3/5 | 71% | 3 h 8 min | 1 worse |
| HCA Florida Lake City HospitalSame ZIP area · Lake City | 3/5 | 63% | 1 h 54 min | 2 better 2 worse |
| Lake Butler HospitalSame ZIP area · Lake Butler | Not rated | 96% | 1 h 32 min | — |
| HCA Florida Orange Park HospitalSame ZIP area · Orange Park | 3/5 | 63% | 1 h 35 min | 4 better 2 worse |
| Flagler HospitalSame ZIP area · Saint Augustine | 3/5 | 63% | 2 h 46 min | 2 better 1 worse |
Hospitals differ in size and in how sick their patients are. CMS adjusts its outcome measures for that, but a star or a percentage is a starting point for questions, not a verdict. All hospitals in Macclenny.
Deaths
How many patients died within 30 days of admission, adjusted by CMS for how sick they were. Lower is better. Data from Jul 2022 – Jun 2025.
| Measure | CMS comparison | This hospital | National |
|---|---|---|---|
| All patients, hospital-wide 158 cases | Too few cases | 4.4% | 3.9% |
| Heart failure 40 cases | Too few cases | 15.2% | 11.1% |
| Pneumonia 61 cases | Too few cases | 16.5% | 15.2% |
| COPD 28 cases | Too few cases | 7.7% | 8.6% |
3 more measures had too few cases here to report.
Complications
How often patients had serious complications, most of them after surgery, adjusted for how sick they were. Lower is better. Data from Jul 2022 – Jun 2024.
| Measure | CMS comparison | This hospital | National |
|---|---|---|---|
| Pressure ulcers (bed sores) 193 cases | No different | 0.61 per 1,000 likely 0 per 1,000 – 1.93 per 1,000 | 0.63 per 1,000 |
| Collapsed lung caused by a procedure 342 cases | No different | 0.21 per 1,000 likely 0 per 1,000 – 0.45 per 1,000 | 0.21 per 1,000 |
| Broken bones from falls in the hospital 372 cases | No different | 0.27 per 1,000 likely 0.05 per 1,000 – 0.49 per 1,000 | 0.27 per 1,000 |
10 more measures had too few cases here to report.
Readmissions and return visits
How often patients had to come back to a hospital after going home. Lower is better. Data from Jul 2023 – Jun 2025.
| Measure | CMS comparison | This hospital | National |
|---|---|---|---|
| Readmitted after heart failure 63 cases | Too few cases | 21% | 21.3% |
| Readmitted after pneumonia 81 cases | Too few cases | 17.2% | 17.3% |
| Readmitted after COPD 41 cases | Too few cases | 19.9% | 20% |
| Days back in hospital after heart failure 42 cases | Too few cases | 15.2 days per 100 | — |
| Days back in hospital after pneumonia 69 cases | Too few cases | -24.2 days per 100 | — |
| Unplanned visits after an outpatient colonoscopy 171 cases | No different | 13.8 per 1,000 likely 10.2 per 1,000 – 18.6 per 1,000 | 13 per 1,000 |
8 more measures had too few cases here to report.
Not reported for this hospital
CMS had too few cases here to publish results for infections caught in the hospital. That is common at small, rural and specialty hospitals, and says nothing either way about quality.
Clinicians registered at this address
22 clinicians give this hospital's street address as their practice location in NPPES, the federal provider registry. The same address can take in offices and clinics in the building, and a listing does not prove admitting privileges or current employment.
| Specialty | Clinicians |
|---|---|
| Emergency Medicine | 4 |
| Family | 4 |
| Gastroenterology | 2 |
| Pediatrics | 2 |
| Acute Care | 1 |
| Diagnostic Radiology | 1 |
| Family Medicine | 1 |
| Internal Medicine | 1 |
| Pharmacist | 1 |
| Physical Therapist | 1 |
| Podiatrist | 1 |
| Primary Care | 1 |
First 12 alphabetically
How to read this page
- Everything here is published by CMS on Care Compare. We arrange it and explain it; the star ratings and the better / worse verdicts are CMS's, not ours.
- “No different” is the most common result on most measures at most hospitals. CMS only calls a result better or worse when the difference from the national rate is statistically clear.
- Death, complication and readmission rates are adjusted by CMS for how sick patients were, so hospitals that treat sicker patients can be compared fairly.
- Infection results are ratios: 1.0 means as many infections as CMS predicted for a hospital like this one, below 1.0 is fewer.
- These are hospital-wide results. They do not rate an individual doctor, nurse or department, and they are not medical advice.
CMS Care Compare data retrieved 4 Oct 2026, refreshed weekly. Where this data comes from and how we handle it · Report an error
Common questions about Ed Fraser Memorial Hospital
Is Ed Fraser Memorial Hospital a good hospital?
Ed Fraser Memorial Hospital has a CMS overall rating of 1 out of 5 stars. Of the 7 death, complication, infection and readmission measures CMS could compare, it does better than the nation on none and worse on 1. These are hospital-wide results published by CMS; they do not rate individual doctors or departments.
Would patients recommend Ed Fraser Memorial Hospital?
75% of patients who answered CMS's national survey would definitely recommend it, against a US average of 71%. The figure comes from 63 completed HCAHPS surveys.
How long is the wait in the Ed Fraser Memorial Hospital emergency room?
Emergency patients spend a median of 2 h 36 min in its emergency department before leaving (US median 2 h 42 min). Among US emergency departments with low patient volume, like this one, the median is 2 h 3 min. 2% of emergency patients left before being seen (US 2%). These are medians over a year of visits, not a live wait time.