Hospital record · FY2026CCN 520021
1Hospital
Froedtert South Inc.
3Type
Not a teaching hospital · 380 beds · Government · Urban · Rural referral center
4Care Compare stars
2 of 5 stars
5Total HAC Score
0.8888
6Payment reduction
Cut 1%
$253K
cut from its FY2026 Medicare inpatient payments, this site estimates estimate
For fiscal year 2026, CMS reports a Total HAC Score of 0.8888 for Froedtert South Inc. and a payment reduction decision of Yes.
That is 1% of about $25.3M, this site’s estimate of what traditional Medicare pays it for inpatient stays in a year: about $146 per traditional Medicare stay.
Likely range $193–318K
Its score was above CMS’s line, so CMS cut its Medicare inpatient payments by 1% for the year. The score compares hospitals with each other; it is not a grade of the quality of care.
CMS cut scores of 0.3799 and above.
Each year CMS cuts the hospitals with the highest quarter of scores, those above the 75th percentile, so the line moves with other hospitals’ scores.
Higher than 91% of the other 2,928 scores CMS published (higher is worse).
Its record, fiscal years 2015 to 2026 Cut in 5 of 11 years
- 15No
- 16No
- 17No
- 18No
- 19Cut
- 20Cut
- 21No
- 22No
- 23—
- 24Cut
- 25Cut
- 26Cut
Where the score came from
CMS scored this hospital on all 6 measures. On every measure a lower value is better. Each row puts the hospital among every hospital with a value: the gray columns are those hospitals, the tall tick is the national median, and the hatched ends score the same as CMS’s floor or cap.
Bringing CDI down to the national median (0.346) would lower the score the most: by 0.3859, to 0.5029. Try it in the what-if
- This hospital
- National median
- Scores the same as CMS’s floor or cap
-
PSI 90 (what it counts)
Safety problems such as serious bedsores, falls that break a bone and blood clots after surgery, found by CMS in traditional Medicare claims. A value of 1 matches the national composite value.
Patient safety and adverse events composite
Worse than 88% of the other 2,808 hospitals
estimate
This site recomputes this measure’s z‑score from CMS’s published value. The recompute can differ from CMS’s z‑score by up to 0.0021. How this site estimates
CMS value1.1800
Z-score1.3369
Part of score+0.2228
-
CLABSI (what it counts)
Bloodstream infections tied to a central line, a tube often placed in a large vein in the neck, chest or groin. Hospitals report them to the CDC’s National Healthcare Safety Network. A value of 1.0 means as many infections as the CDC’s model predicted.
Central line–associated bloodstream infections
Worse than 78% of the other 2,181 hospitals
CMS value0.927
Z-score0.7440
Part of score+0.1240
-
CAUTI (what it counts)
Urinary tract infections that start from a urinary catheter, a tube that drains the bladder. Hospitals report them to the CDC’s National Healthcare Safety Network. A value of 1.0 means as many infections as the CDC’s model predicted.
Catheter-associated urinary tract infections
Worse than 72% of the other 2,354 hospitals
CMS value0.730
Z-score0.4411
Part of score+0.0735
-
SSI (what it counts)
Deep infections at the site of colon surgery or an abdominal hysterectomy, within a month of the operation, pooled into one measure. Hospitals report them to the CDC’s National Healthcare Safety Network. A value of 1.0 means as many infections as the CDC’s model predicted.
Surgical site infections after colon surgery or abdominal hysterectomy
Worse than 68% of the other 2,269 hospitals
CMS value1.071
Z-score0.3782
Part of score+0.0630
-
added the most
CDI (what it counts)
C. diff infections, which cause diarrhea and inflammation of the colon, found by a lab test and starting in the hospital. Hospitals report them to the CDC’s National Healthcare Safety Network. A value of 1.0 means as many infections as the CDC’s model predicted.
Clostridioides difficile (C. diff) infections
Worse than 95% of the other 2,766 hospitals
estimate
This site recomputes this measure’s z‑score from CMS’s published value. The recompute can differ from CMS’s z‑score by up to 0.0071. How this site estimates
CMS value0.953
Z-score2.1931
Part of score+0.3655
-
MRSA (what it counts)
Bloodstream infections with MRSA, a germ that resists several antibiotics, found by a lab test and starting in the hospital. Hospitals report them to the CDC’s National Healthcare Safety Network. A value of 1.0 means as many infections as the CDC’s model predicted.
MRSA bloodstream infections
Worse than 64% of the other 2,067 hospitals
CMS value0.812
Z-score0.2397
Part of score+0.0400
Source: CMS Provider Data Catalog, HACRP FY2026 (yq43-i98g), released August 13, 2026.
Show table
| Measure | CMS value | National median | Z-score | Part of the score | Among hospitals |
|---|---|---|---|---|---|
| PSI 90 | 1.1800 | 0.9623 | 1.3369 | +0.2228 | Worse than 88% of the other 2,808 hospitals |
| CLABSI | 0.927 | 0.559 | 0.7440 | +0.1240 | Worse than 78% of the other 2,181 hospitals |
| CAUTI | 0.730 | 0.489 | 0.4411 | +0.0735 | Worse than 72% of the other 2,354 hospitals |
| SSI | 1.071 | 0.795 | 0.3782 | +0.0630 | Worse than 68% of the other 2,269 hospitals |
| CDI | 0.953 | 0.346 | 2.1931 | +0.3655 | Worse than 95% of the other 2,766 hospitals |
| MRSA | 0.812 | 0.641 | 0.2397 | +0.0400 | Worse than 64% of the other 2,067 hospitals |
How the parts add up
CMS adds the z‑scores and divides by the number of measures scored, so each measure counts the same. Each bar below is one z‑score divided by 6; a bar right of zero raised the score and one left of zero lowered it.
(1.3369PSI 90+0.7440CLABSI+0.4411CAUTI+0.3782SSI+2.1931CDI+0.2397MRSA)÷6measures=0.8888Total HAC Score
This hospital’s score is 0.5096 above 0.3792, the highest score CMS marked No. (This site recomputes.)
This site recomputes · Source: CMS Provider Data Catalog, HACRP FY2026 (yq43-i98g), released August 13, 2026.
Show table
| Measure | Z-score | Part of the score | Running total |
|---|---|---|---|
| PSI 90 | 1.3369 | +0.2228 | 0.2228 |
| CLABSI | 0.7440 | +0.1240 | 0.3468 |
| CAUTI | 0.4411 | +0.0735 | 0.4203 |
| SSI | 0.3782 | +0.0630 | 0.4833 |
| CDI | 2.1931 | +0.3655 | 0.8488 |
| MRSA | 0.2397 | +0.0400 | 0.8888 |
| Total HAC Score | 0.8888 | ||
| CMS’s line | 0.3792 | 0.3799 |
The money is a cliff
This program’s cut doesn’t grow with the score. Over CMS’s line, CMS cuts 1% of what traditional Medicare pays a hospital for inpatient stays that year; at or under the line, this program cuts nothing.
The chart draws what the cut would be for this hospital at any Total HAC Score, from this site’s estimate of its payments, with its own score marked.
Under the axis, every Total HAC Score CMS published: 306 of the 2,929 scored within 0.1 of CMS’s line, on one side or the other.
Estimate · Source: this site’s arithmetic on CMS’s FY2026 IPPS final rule files (the impact file, the rate tables and the value-based factors), its FY2026 HRRP supplemental file and HACRP FY2026 (yq43-i98g), released August 13, 2026.
Show table
| Score | Total HAC Score | Estimated HAC cut (whole dollars) |
|---|---|---|
| Any score up to 0.3792 | 0.3792 | $0 |
| Any score from 0.3799 | 0.3799 | −$252,980 |
| This hospital | 0.8888 | −$252,980 |
| CMS’s highest score | 2.3133 | −$252,980 |
The money, line by line
This site estimates what traditional Medicare pays the hospital for a year of inpatient stays, from CMS’s FY2026 payment files, then applies Medicare’s three hospital quality programs: the readmissions and value-based adjustments to the base payment, and the HAC cut last, as the law sets.
The readmissions and value-based programs adjust only the base payment: the DRG rates times the hospital’s cases, and a Medicare-dependent hospital’s add-on. The HAC cut comes last and takes 1% of everything left, teaching, low-income-patient, outlier, capital and uncompensated care payments included.
($25,420,866payment−$76,598readmissions−$46,307value-based)×1%the cut=$252,980HAC cut
$252,980HAC cut÷1,738traditional Medicare stays=$146per traditional Medicare stay
Estimated Medicare inpatient payments · FY2026 estimate
| What traditional Medicare pays it for inpatient stays | ||
|---|---|---|
| DRG payments at the federal rates the base | $19,640,534 | |
| Many low-income patients (disproportionate share) | $280,467 | |
| Outliers: unusually costly stays | $1,578,706 | |
| Capital: buildings and equipment | $1,830,901 | |
| Uncompensated care | $2,090,258 | |
| Total, before the three programs | $25,420,866 | |
| The three programs: two on the base, the HAC cut last | ||
| Readmissions (HRRP) base × (0.9961 − 1) | −$76,598 | |
| Value-based purchasing (HVBP) base × (0.9976 − 1) | −$46,307 | |
| After these two | $25,297,961 | |
| HAC Reduction Program 1% of everything above; likely $193–318K | −$252,980 | |
| Net of the three programs likely −$442K to −$303K | −$375,885 | |
Not paid to this hospital: a Medicare-dependent hospital add-on, teaching payments, a sole community hospital rate difference, and a low-volume adjustment.
Whole dollars, so every line adds up; the estimate is not that precise. Each likely range spans the middle 80% of the misses this site’s estimate made for similar hospitals (or for a wider group, where there were too few) when it was checked against their FY2024 cost reports: one year’s check, not a promise of how often a hospital’s actual figure lands inside.
Estimate · Source: this site’s arithmetic on CMS’s FY2026 IPPS final rule files (the impact file, the rate tables and the value-based factors), its FY2026 HRRP supplemental file and HACRP FY2026 (yq43-i98g), released August 13, 2026.
Show table
| Line | Amount (whole dollars) |
|---|---|
| DRG payments at the federal rates (the base) | $19,640,534 |
| Many low-income patients (disproportionate share) | $280,467 |
| Outliers: unusually costly stays | $1,578,706 |
| Capital: buildings and equipment | $1,830,901 |
| Uncompensated care | $2,090,258 |
| Total, before the three programs | $25,420,866 |
| Readmissions (HRRP) (base × (0.9961 − 1)) | −$76,598 |
| Value-based purchasing (HVBP) (base × (0.9976 − 1)) | −$46,307 |
| After these two | $25,297,961 |
| HAC Reduction Program (1% of everything above; likely $193–318K) | −$252,980 |
| Net of the three programs (likely −$442K to −$303K) | −$375,885 |
What if a measure were different?
Change a measure’s value to see how this site recomputes the Total HAC Score, the payment reduction decision and, by its estimate, the money, starting from CMS’s values. The money doesn’t slide with the score: it drops off a cliff at CMS’s line.
The what-if needs JavaScript. Without it, the values below stay as they are.
Show table
| CMS reports | Hypothetical | |
|---|---|---|
| Total HAC Score | 0.8888 | same |
| Payment reduction decision | Yes | same |
| Payment cut | 1% | same |
| Estimated HAC cut estimate | $253K | same |
CMS’s line: between 0.3792 and 0.3799
The faint ticks are CMS’s line in earlier years under the same formula, from about 0.300 (FY2022) to about 0.375 (FY2024). The line moves every year, so a hospital can cross it without changing anything.
CMS reports a Total HAC Score of 0.8888 and a payment reduction decision of Yes.
Estimate: a changed measure’s z‑score is this site’s recompute, which can differ slightly from CMS’s. How this site estimates
A what-if shows the formula’s arithmetic, not what a hospital could realistically change or how. CMS’s real result also depends on other hospitals.
Bring all to the national median lowers each measure above its national median to that median and leaves the measures CMS assigned as they are.
What would it take?
Getting under CMS’s line would keep about $253K, this site estimates: the whole cut, however far under the score lands.
From CMS’s values, one measure at a time, with every other measure held at CMS’s value.
| Measure | Value that would read No |
|---|---|
| PSI 90 | not possible with this measure alone |
| CLABSI | not possible with this measure alone |
| CAUTI | not possible with this measure alone |
| SSI | not possible with this measure alone |
| CDI | 0.154 or lower |
| MRSA | not possible with this measure alone |
Each measure weighs 1 ÷ 6 of the score.
This site recomputes · Source: CMS Provider Data Catalog, HACRP FY2026 (yq43-i98g), released August 13, 2026.
Show table
| Measure | Z-score | Part of the score | Hypothetical |
|---|---|---|---|
| PSI 90 | 1.3369 | +0.2228 | same |
| CLABSI | 0.7440 | +0.1240 | same |
| CAUTI | 0.4411 | +0.0735 | same |
| SSI | 0.3782 | +0.0630 | same |
| CDI | 2.1931 | +0.3655 | same |
| MRSA | 0.2397 | +0.0400 | same |
Interactive what-if at https://paidandpenalized.org/hacrp/hospital/520021/
Among hospitals with a Yes or No payment decision, CMS cut those with a published Total HAC Score of 0.3799 or higher and none at 0.3792 or lower. Maryland’s hospitals are scored but not subject to the reduction.
Held fixed: every other hospital’s results, CMS’s line, and each measure’s mean, spread, floor and cap as this site fits them to CMS’s published values.
Year by year
Where this hospital’s score fell among every hospital’s, each year CMS published one. A score near the top is among the highest; the shaded band is where CMS cut. Places compare across years even where CMS changed how it builds the score.
Its longest run: cut 3 years in a row.
● Red: a year CMS cut it ○ Hollow: a year it didn’t
This site recomputes · Source: CMS, HACRP hospital files for fiscal years 2015 to 2026 (Provider Data Catalog, its archives and, for the oldest years, the Internet Archive’s copies), and CMS’s cut lists for FY2015 and FY2016.
Show table
| Fiscal year | Total HAC Score | Higher than this share of scores | Payment reduction |
|---|---|---|---|
| FY2015 | 2.0000 | 4.7% | not cut |
| FY2016 | 2.2500 | 6.2% | not cut |
| FY2017 | 3.9200 | 24.7% | not cut |
| FY2018 | −0.1610 | 39.6% | not cut |
| FY2019 | 0.8147 | 91.4% | cut |
| FY2020 | 0.5915 | 86.0% | cut |
| FY2021 | 0.1755 | 66.5% | not cut |
| FY2022 | 0.1928 | 68.7% | not cut |
| FY2023 | no decision | ||
| FY2024 | 1.2431 | 95.9% | cut |
| FY2025 | 1.2273 | 96.5% | cut |
| FY2026 | 0.8888 | 91.8% | cut |
Its infections, year by year
This hospital’s infection rate against prediction for each calendar year Care Compare published one, on each measure with at least two years of results (black), over the nation’s middle hospital (gray). Below the dashed line at one, fewer infections than predicted. Each year is measured against the same fixed baseline, not against other hospitals, so unlike the score they can all improve at once.
Source: CMS Care Compare, healthcare-associated infections by hospital, calendar years 2017 to 2024 (Provider Data Catalog archives; the oldest year through the Internet Archive’s copy).
Show table
| Calendar year | CLABSI | CAUTI | SSI, colon | MRSA | C. diff |
|---|---|---|---|---|---|
| 2017 | 1.104 | 2.072 | 1.555 | 0.754 | 1.251 |
| 2018 | 1.441 | 1.153 | 0.636 | 0.654 | 0.681 |
| 2019 | 0.338 | 0.401 | 0.941 | 1.675 | 1.012 |
| 2021 | 1.384 | 1.406 | 3.652 | 1.352 | 2.062 |
| 2022 | 1.253 | 1.821 | 2.995 | 1.019 | 2.093 |
| 2023 | 0.621 | 0.821 | 1.336 | 0.520 | 1.337 |
| 2024 | 1.229 | 0.636 | 0.978 | 1.129 | 0.754 |
Among hospitals like it
Each row is a group this hospital belongs to, drawn from every hospital in it with a payment decision. Red columns are hospitals past CMS’s line, the ones CMS cut; the short tick is the group’s middle score.
In Wisconsin, its score is higher than 96% of the other 61 scored there.
Source: CMS Provider Data Catalog, HACRP FY2026 (yq43-i98g), released August 13, 2026.
Show table
| Group | With a decision | Hospitals cut | Share cut | Middle score | Hospital higher than |
|---|---|---|---|---|---|
| All hospitals | 2,886 | 718 | 25% | −0.0453 | 91% |
| Midwest region | 683 | 174 | 25% | −0.0268 | 92% |
| Wisconsin | 62 | 16 | 26% | 0.0996 | 96% |
| Not teaching | 1,563 | 389 | 25% | −0.1053 | 89% |
| 300 to 499 beds | 523 | 113 | 22% | −0.0384 | 95% |
| Government | 401 | 140 | 35% | 0.1602 | 84% |
| Urban | 2,241 | 510 | 23% | −0.0574 | 93% |
| This hospital | 0.8888 | ||||
| CMS’s line | 0.3792 | 0.3799 |
The nearest hospitals
The 8 closest hospitals with a Total HAC Score, in a straight line. The squares are each hospital’s measures in order: filled, above the national median; open, at or below it; hatched, assigned by CMS; blank, not scored.
Source: CMS Provider Data Catalog, HACRP FY2026 (yq43-i98g), released August 13, 2026.
Show table
| Hospital | Miles | Score | Decision |
|---|---|---|---|
| Aurora Medical Center Kenosha, Kenosha, WI | 4 | 0.6506 | cut |
| Midwestern Region Med Center, Inc, Zion, IL | 9 | 0.3020 | not cut |
| Ascension All Saints Hospital, Racine, WI | 11 | 0.0943 | not cut |
| Vista Medical Center East, Waukegan, IL | 14 | −0.6736 | not cut |
| Midwest Orthopedic Specialty Hospital, Franklin, WI | 21 | −0.3350 | not cut |
| Advocate Condell Medical Center, Libertyville, IL | 22 | −0.1754 | not cut |
| Northwestern Lake Forest Hospital, Lake Forest, IL | 22 | −0.1778 | not cut |
| Aurora Memorial Hospital Burlington, Burlington, WI | 24 | 0.6344 | cut |
Arrow keys step through the measures.
| # | Hospital | Miles | Score | Decision | Est. cut ($, modeled) | Measures |
|---|---|---|---|---|---|---|
| 1 | Aurora Medical Center KenoshaKenosha, WI | 4 | 0.6506 | 1% cut | $258K | Above the national median on 5 of 6 measures |
| 2 | Midwestern Region Med Center, IncZion, IL | 9 | 0.3020 | No cut | $0 | Above the national median on 3 of 3 measures |
| 3 | Ascension All Saints HospitalRacine, WI | 11 | 0.0943 | No cut | $0 | Above the national median on 3 of 6 measures |
| 4 | Vista Medical Center EastWaukegan, IL | 14 | −0.6736 | No cut | $0 | Above the national median on 1 of 6 measures |
| 5 | Midwest Orthopedic Specialty HospitalFranklin, WI | 21 | −0.3350 | No cut | $0 | Above the national median on 0 of 1 measures |
| 6 | Advocate Condell Medical CenterLibertyville, IL | 22 | −0.1754 | No cut | $0 | Above the national median on 4 of 6 measures |
| 7 | Northwestern Lake Forest HospitalLake Forest, IL | 22 | −0.1778 | No cut | $0 | Above the national median on 3 of 6 measures |
| 8 | Aurora Memorial Hospital BurlingtonBurlington, WI | 24 | 0.6344 | 1% cut | $90K | Above the national median on 3 of 5 measures |
A penalty reflects how CMS’s formula scored relative performance; it is not a verdict on the quality of care.
Cite this page
Paid & Penalized. Froedtert South Inc., Kenosha, WI: Hospital-Acquired Conditions, FY2026. https://paidandpenalized.org/hacrp/hospital/520021/. Source: CMS Provider Data Catalog, HACRP FY2026 (yq43-i98g), released August 13, 2026.