JCIPatientSafety.orgHospital Quality Directory

Critical Access Hospitals · Voluntary non-profit - Private

Frances Mahon Deaconess Hospital

Not rated overall

CMS reports safety and quality measures for this hospital but does not assign an overall star rating. See scores below.

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 Limit—Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit—Not available
Central Line Associated Bloodstream Infection: Number of Device Days146Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases0.040Not 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 Limit—Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit—Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days272Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases0.178Not 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 Limit—Not available
SSI - Colon Surgery: Upper Confidence Limit—Not available
SSI - Colon Surgery: Number of Procedures3Not available
SSI - Colon Surgery: Predicted Cases0.073Not available
SSI - Colon Surgery: Observed Cases1Not available
SSI - Colon Surgery—Not available
SSI - Abdominal Hysterectomy: Lower Confidence Limit—Not available
SSI - Abdominal Hysterectomy: Upper Confidence Limit—Not available
SSI - Abdominal Hysterectomy: Number of Procedures—Not available
SSI - Abdominal Hysterectomy: Predicted Cases—Not available
SSI - Abdominal Hysterectomy: Observed Cases—Not available
SSI - Abdominal Hysterectomy—Not available
MRSA Bacteremia: Lower Confidence Limit—Not available
MRSA Bacteremia: Upper Confidence Limit—Not available
MRSA Bacteremia: Patient Days1595Not available
MRSA Bacteremia: Predicted Cases0.033Not available
MRSA Bacteremia: Observed Cases0Not available
MRSA Bacteremia—Not available
Clostridium Difficile (C.Diff): Lower Confidence Limit—Not available
Clostridium Difficile (C.Diff): Upper Confidence Limit—Not available
Clostridium Difficile (C.Diff): Patient Days1595Not available
Clostridium Difficile (C.Diff): Predicted Cases0.352Not available
Clostridium Difficile (C.Diff): Observed Cases0Not available
Clostridium Difficile (C.Diff)—Not available

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 patients—Not available—
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate6.1Worse than national75
Death rate for heart attack patients—Not available—
Death rate for CABG surgery patients—Not available—
Death rate for COPD patients—Not available—
Death rate for heart failure patients—Not available—
Death rate for pneumonia patients21Same as national42
Death rate for stroke patients—Not available—
Pressure ulcer rate—Not available—
Death rate among surgical inpatients with serious treatable complications—Not available—
Iatrogenic pneumothorax rate—Not available—
In-hospital fall-associated fracture rate—Not available—
Postoperative hemorrhage or hematoma rate—Not available—
Postoperative acute kidney injury requiring dialysis rate—Not available—
Postoperative respiratory failure rate—Not available—
Perioperative pulmonary embolism or deep vein thrombosis rate—Not available—
Postoperative sepsis rate—Not available—
Postoperative wound dehiscence rate—Not available—
Abdominopelvic accidental puncture or laceration rate—Not available—
CMS Medicare PSI 90: Patient safety and adverse events composite—Not available—

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 patients—Not available—
Hospital return days for heart failure patients—Not available—
Hospital return days for pneumonia patients-24.8Not available42
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)15.6Same as national104
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)12.7Same as national281
Rate of inpatient admissions for patients receiving outpatient chemotherapy9.4Same as national30
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy5.8Same as national30
Ratio of unplanned hospital visits after hospital outpatient surgery1Same as national45
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate—Not available—
Rate of readmission for CABG—Not available—
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients—Not available—
Heart failure (HF) 30-Day Readmission Rate—Not available—
Rate of readmission after hip/knee replacement—Not available—
Pneumonia (PN) 30-Day Readmission Rate15.6Same as national42

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 rating—57
Doctor communication - star rating—57
Communication about medicines - star rating—57
Discharge information - star rating—57
Cleanliness - star rating—57
Quietness - star rating—57
Overall hospital rating - star rating—57
Recommend hospital - star rating—57
Summary star rating—57

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 volume——
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 Hyperglycemia16161
Hospital Harm - Severe Hypoglycemia044
Hospital Harm - Opioid Related Adverse Events——
Healthcare workers given influenza vaccination78282
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 better144196
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 better122174
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 better28719
Left before being seen——
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 Prescribing9102
Appropriate care for severe sepsis and septic shock——
Septic Shock 3-Hour Bundle——
Septic Shock 6-Hour Bundle——
Severe Sepsis 3-Hour Bundle——
Severe Sepsis 6-Hour Bundle——
Discharged on Antithrombotic Therapy——
Anticoagulation Therapy for Atrial Fibrillation/Flutter——
Antithrombotic Therapy by End of Hospital Day 2——
Venous Thromboembolism Prophylaxis64170
Intensive Care Unit Venous Thromboembolism Prophylaxis——

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 Measure——

Frequently asked questions

How is Frances Mahon Deaconess Hospital rated?
CMS does not assign an overall star rating to Frances Mahon Deaconess Hospital, but does publish underlying safety and quality measures shown on this page.
Does Frances Mahon Deaconess Hospital have emergency services?
Yes. Frances Mahon Deaconess Hospital operates a 24/7 emergency department.
Where is Frances Mahon Deaconess Hospital located?
Frances Mahon Deaconess Hospital is located at 621 3rd St S, Glasgow, MT 59230.
What type of hospital is Frances Mahon Deaconess Hospital?
Frances Mahon Deaconess Hospital is classified by CMS as a Critical Access 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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