JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Mount St. Mary's Hospital & Health Center

2 / 5

At a glance

Mount St. Mary's Hospital & Health Center 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 LimitNot available
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence LimitNot available
Central Line Associated Bloodstream Infection: Number of Device Days446Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases0.270Not 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 Days1113Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases0.709Not 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 ProceduresNot available
SSI - Colon Surgery: Predicted CasesNot available
SSI - Colon Surgery: Observed CasesNot available
SSI - Colon SurgeryNot available
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of ProceduresNot available
SSI - Abdominal Hysterectomy: Predicted CasesNot available
SSI - Abdominal Hysterectomy: Observed CasesNot available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitSame as national
MRSA Bacteremia: Upper Confidence Limit2.984Same as national
MRSA Bacteremia: Patient Days31541Same as national
MRSA Bacteremia: Predicted Cases1.004Same as national
MRSA Bacteremia: Observed Cases0Same as national
MRSA Bacteremia0.000Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.007Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.701Better than national
Clostridium Difficile (C.Diff): Patient Days31541Better than national
Clostridium Difficile (C.Diff): Predicted Cases7.034Better than national
Clostridium Difficile (C.Diff): Observed Cases1Better than national
Clostridium Difficile (C.Diff)0.142Better 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 Rate4.2Same as national260
Death rate for heart attack patientsNot available
Death rate for CABG surgery patientsNot available
Death rate for COPD patients7.1Same as national53
Death rate for heart failure patients12.9Same as national96
Death rate for pneumonia patients19.5Same as national111
Death rate for stroke patients12.4Same as national51
Pressure ulcer rate0.46Same as national952
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.20Same as national1168
In-hospital fall-associated fracture rate0.26Same as national1186
Postoperative hemorrhage or hematoma rate2.63Same as national70
Postoperative acute kidney injury requiring dialysis rateNot available
Postoperative respiratory failure rateNot available
Perioperative pulmonary embolism or deep vein thrombosis rate4.40Same as national72
Postoperative sepsis rateNot available
Postoperative wound dehiscence rateNot available
Abdominopelvic accidental puncture or laceration rate1.03Same as national101
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 patients58.9Not available118
Hospital return days for pneumonia patients99.2Not available117
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)15.3Same as national362
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)12.5Same as national225
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 RateNot available
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients18.6Same as national59
Heart failure (HF) 30-Day Readmission Rate19.9Same as national118
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate17.9Same as national117

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 rating4383
Doctor communication - star rating4383
Communication about medicines - star rating3383
Discharge information - star rating4383
Cleanliness - star rating3383
Quietness - star rating4383
Overall hospital rating - star rating4383
Recommend hospital - star rating4383
Summary star rating4383

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 volumehigh
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 Events0887
Healthcare workers given influenza vaccination622262
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 better167401
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 better163372
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 better27020
Left before being seen140957
Head CT results7726
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients10071
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing15551
Appropriate care for severe sepsis and septic shock32122
Septic Shock 3-Hour Bundle5522
Septic Shock 6-Hour Bundle
Severe Sepsis 3-Hour Bundle44124
Severe Sepsis 6-Hour Bundle9328
Discharged on Antithrombotic Therapy
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 29648
Venous Thromboembolism Prophylaxis921456
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 MeasureNot Applicable (our hospital does not provide inpatient labor/delivery care)

Frequently asked questions

How is Mount St. Mary's Hospital & Health Center rated?
Mount St. Mary's Hospital & Health Center has a 2 out of 5 CMS overall star rating as of the latest CMS release.
Does Mount St. Mary's Hospital & Health Center have emergency services?
Yes. Mount St. Mary's Hospital & Health Center operates a 24/7 emergency department.
Where is Mount St. Mary's Hospital & Health Center located?
Mount St. Mary's Hospital & Health Center is located at 5300 Military Road, Lewiston, NY 14092.
What type of hospital is Mount St. Mary's Hospital & Health Center?
Mount St. Mary's Hospital & Health Center 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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