JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Bon Secours Community Hospital

2 / 5

At a glance

Bon Secours Community Hospital carries a 2-star CMS overall rating — below 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 Days268Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases0.195Not 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 Days934Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases0.644Not 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 Procedures9Not available
SSI - Colon Surgery: Predicted Cases0.235Not 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 Procedures11Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.078Not 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 Days7589Not available
MRSA Bacteremia: Predicted Cases0.279Not available
MRSA Bacteremia: Observed Cases0Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence Limit0.078Same as national
Clostridium Difficile (C.Diff): Upper Confidence Limit1.545Same as national
Clostridium Difficile (C.Diff): Patient Days7589Same as national
Clostridium Difficile (C.Diff): Predicted Cases4.278Same as national
Clostridium Difficile (C.Diff): Observed Cases2Same as national
Clostridium Difficile (C.Diff)0.468Same 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 Rate3.9Same as national347
Death rate for heart attack patients11.8Same as national26
Death rate for CABG surgery patientsNot available
Death rate for COPD patients9.5Same as national94
Death rate for heart failure patients13.4Same as national159
Death rate for pneumonia patients15.9Same as national138
Death rate for stroke patientsNot available
Pressure ulcer rate0.43Same as national1213
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.20Same as national1533
In-hospital fall-associated fracture rate0.26Same as national1509
Postoperative hemorrhage or hematoma rate2.63Same as national91
Postoperative acute kidney injury requiring dialysis rateNot available
Postoperative respiratory failure rateNot available
Perioperative pulmonary embolism or deep vein thrombosis rate3.38Same as national91
Postoperative sepsis rateNot available
Postoperative wound dehiscence rate1.74Same as national41
Abdominopelvic accidental puncture or laceration rate1.02Same as national138
CMS Medicare PSI 90: Patient safety and adverse events composite0.93Same 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 patients58Not available169
Hospital return days for pneumonia patients8.4Not available140
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)15Same as national496
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)12.7Same as national355
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 surgery0.9Same as national41
Acute Myocardial Infarction (AMI) 30-Day Readmission RateNot available
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients19.6Same as national99
Heart failure (HF) 30-Day Readmission Rate21Same as national169
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate15.2Same as national140

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 rating3237
Doctor communication - star rating2237
Communication about medicines - star rating3237
Discharge information - star rating2237
Cleanliness - star rating4237
Quietness - star rating3237
Overall hospital rating - star rating2237
Recommend hospital - star rating2237
Summary star rating3237

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 volumelow
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 Hypoglycemia0521
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination67729
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 better170402
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 better156358
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better33430
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better40416
Left before being seen119243
Head CT results
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing18210
Appropriate care for severe sepsis and septic shock6295
Septic Shock 3-Hour Bundle9031
Septic Shock 6-Hour Bundle6724
Severe Sepsis 3-Hour Bundle7896
Severe Sepsis 6-Hour Bundle9358
Discharged on Antithrombotic Therapy
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 2
Venous Thromboembolism Prophylaxis831075
Intensive Care Unit Venous Thromboembolism Prophylaxis85223

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 MeasureNot Applicable (our hospital does not provide inpatient labor/delivery care)

Frequently asked questions

How is Bon Secours Community Hospital rated?
Bon Secours Community Hospital has a 2 out of 5 CMS overall star rating as of the latest CMS release.
Does Bon Secours Community Hospital have emergency services?
Yes. Bon Secours Community Hospital operates a 24/7 emergency department.
Where is Bon Secours Community Hospital located?
Bon Secours Community Hospital is located at 160 East Main Street, Port Jervis, NY 12771.
What type of hospital is Bon Secours Community Hospital?
Bon Secours Community Hospital 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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