JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Chan Soon- Shiong Medical Center at Windber

2 / 5

At a glance

Chan Soon- Shiong Medical Center at Windber 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 Days110Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases0.064Not 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 Days432Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases0.211Not 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 Procedures6Not available
SSI - Colon Surgery: Predicted Cases0.183Not 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 Procedures9Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.075Not available
SSI - Abdominal Hysterectomy: Observed Cases1Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitNot available
MRSA Bacteremia: Upper Confidence LimitNot available
MRSA Bacteremia: Patient Days4221Not available
MRSA Bacteremia: Predicted Cases0.119Not available
MRSA Bacteremia: Observed Cases0Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence Limit0.027Same as national
Clostridium Difficile (C.Diff): Upper Confidence Limit2.660Same as national
Clostridium Difficile (C.Diff): Patient Days4221Same as national
Clostridium Difficile (C.Diff): Predicted Cases1.854Same as national
Clostridium Difficile (C.Diff): Observed Cases1Same as national
Clostridium Difficile (C.Diff)0.539Same 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 patients2.9Same as national55
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4.5Same as national87
Death rate for heart attack patientsNot available
Death rate for CABG surgery patientsNot available
Death rate for COPD patientsNot available
Death rate for heart failure patients17.3Same as national46
Death rate for pneumonia patients18.9Same as national43
Death rate for stroke patientsNot available
Pressure ulcer rate0.61Same as national146
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.21Same as national336
In-hospital fall-associated fracture rate0.27Same as national339
Postoperative hemorrhage or hematoma rate2.32Same as national70
Postoperative acute kidney injury requiring dialysis rate1.67Same as national40
Postoperative respiratory failure rate9.11Same as national40
Perioperative pulmonary embolism or deep vein thrombosis rate3.44Same as national74
Postoperative sepsis rate5.18Same as national39
Postoperative wound dehiscence rateNot available
Abdominopelvic accidental puncture or laceration rate1.05Same as national40
CMS Medicare PSI 90: Patient safety and adverse events composite0.98Same 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 patients14.2Not available53
Hospital return days for pneumonia patients60.8Not available49
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)15.5Same as national110
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)12.9Same as national321
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 surgeryNot available
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate13.6Same as national32
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patientsNot available
Heart failure (HF) 30-Day Readmission Rate20.2Same as national53
Rate of readmission after hip/knee replacement5.2Same as national42
Pneumonia (PN) 30-Day Readmission Rate16.4Same as national49

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 rating5291
Doctor communication - star rating3291
Communication about medicines - star rating3291
Discharge information - star rating4291
Cleanliness - star rating4291
Quietness - star rating4291
Overall hospital rating - star rating4291
Recommend hospital - star rating5291
Summary star rating4291

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 Hypoglycemia
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination78709
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 better137356
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 better133331
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better46617
Left before being seen69202
Head CT results
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients9852
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing15173
Appropriate care for severe sepsis and septic shock5231
Septic Shock 3-Hour Bundle
Septic Shock 6-Hour Bundle
Severe Sepsis 3-Hour Bundle7731
Severe Sepsis 6-Hour Bundle8318
Discharged on Antithrombotic Therapy
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 2
Venous Thromboembolism Prophylaxis45754
Intensive Care Unit Venous Thromboembolism Prophylaxis0

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 Chan Soon- Shiong Medical Center at Windber rated?
Chan Soon- Shiong Medical Center at Windber has a 2 out of 5 CMS overall star rating as of the latest CMS release.
Does Chan Soon- Shiong Medical Center at Windber have emergency services?
Yes. Chan Soon- Shiong Medical Center at Windber operates a 24/7 emergency department.
Where is Chan Soon- Shiong Medical Center at Windber located?
Chan Soon- Shiong Medical Center at Windber is located at 600 Somerset Avenue, Windber, PA 15963.
What type of hospital is Chan Soon- Shiong Medical Center at Windber?
Chan Soon- Shiong Medical Center at Windber 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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