JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Church

Deaconess Henderson Hospital

2 / 5

At a glance

Deaconess Henderson Hospital carries a 2-star CMS overall rating — below the national norm. On healthcare-associated infection measures, it performs better than the national average on 6 and worse on 0.

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 LimitSame as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit1.408Same as national
Central Line Associated Bloodstream Infection: Number of Device Days2981Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases2.127Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases0Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.000Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence LimitSame as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit1.273Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days3197Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases2.354Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases0Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.000Same as national
SSI - Colon Surgery: Lower Confidence Limit0.202Same as national
SSI - Colon Surgery: Upper Confidence Limit3.978Same as national
SSI - Colon Surgery: Number of Procedures61Same as national
SSI - Colon Surgery: Predicted Cases1.661Same as national
SSI - Colon Surgery: Observed Cases2Same as national
SSI - Colon Surgery1.204Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures15Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.188Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitSame as national
MRSA Bacteremia: Upper Confidence Limit1.981Same as national
MRSA Bacteremia: Patient Days26878Same as national
MRSA Bacteremia: Predicted Cases1.512Same as national
MRSA Bacteremia: Observed Cases0Same as national
MRSA Bacteremia0.000Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.004Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.354Better than national
Clostridium Difficile (C.Diff): Patient Days25180Better than national
Clostridium Difficile (C.Diff): Predicted Cases13.917Better than national
Clostridium Difficile (C.Diff): Observed Cases1Better than national
Clostridium Difficile (C.Diff)0.072Better than 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 Rate4Same as national469
Death rate for heart attack patientsNot available
Death rate for CABG surgery patientsNot available
Death rate for COPD patients12.3Same as national46
Death rate for heart failure patients12.2Same as national156
Death rate for pneumonia patients13.8Same as national135
Death rate for stroke patients15.7Same as national67
Pressure ulcer rate0.33Same as national1393
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.20Same as national1881
In-hospital fall-associated fracture rate0.30Same as national1920
Postoperative hemorrhage or hematoma rate2.28Same as national124
Postoperative acute kidney injury requiring dialysis rateNot available
Postoperative respiratory failure rateNot available
Perioperative pulmonary embolism or deep vein thrombosis rate3.72Same as national134
Postoperative sepsis rateNot available
Postoperative wound dehiscence rate1.73Same as national40
Abdominopelvic accidental puncture or laceration rate1.25Same as national356
CMS Medicare PSI 90: Patient safety and adverse events composite0.99Same 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 patients27.3Not available173
Hospital return days for pneumonia patients-15Not available143
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)15.1Same as national784
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)12.5Same as national416
Rate of inpatient admissions for patients receiving outpatient chemotherapy10Same as national48
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy4.9Same as national48
Ratio of unplanned hospital visits after hospital outpatient surgery1.1Same as national80
Acute Myocardial Infarction (AMI) 30-Day Readmission RateNot available
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients17.7Same as national44
Heart failure (HF) 30-Day Readmission Rate21.2Same as national173
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate15.5Same as national143

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 rating3545
Doctor communication - star rating3545
Communication about medicines - star rating2545
Discharge information - star rating3545
Cleanliness - star rating3545
Quietness - star rating4545
Overall hospital rating - star rating3545
Recommend hospital - star rating2545
Summary star rating3545

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 volumemedium
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 vaccination81989
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 better130404
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 better127364
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better14021
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better26020
Left before being seen225753
Head CT results
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients9978
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing151586
Appropriate care for severe sepsis and septic shock77112
Septic Shock 3-Hour Bundle7434
Septic Shock 6-Hour Bundle9623
Severe Sepsis 3-Hour Bundle90112
Severe Sepsis 6-Hour Bundle9376
Discharged on Antithrombotic Therapy99169
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 299146
Venous Thromboembolism Prophylaxis
Intensive Care Unit Venous Thromboembolism Prophylaxis98879

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 MeasureYes

Frequently asked questions

How is Deaconess Henderson Hospital rated?
Deaconess Henderson Hospital has a 2 out of 5 CMS overall star rating as of the latest CMS release.
Does Deaconess Henderson Hospital have emergency services?
Yes. Deaconess Henderson Hospital operates a 24/7 emergency department.
Where is Deaconess Henderson Hospital located?
Deaconess Henderson Hospital is located at 1305 N Elm St, Henderson, KY 42420.
What type of hospital is Deaconess Henderson Hospital?
Deaconess Henderson Hospital is classified by CMS as a Acute Care Hospitals facility (Voluntary non-profit - Church).

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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