JCIPatientSafety.orgHospital Quality Directory

Critical Access Hospitals · Voluntary non-profit - Private

Penn Highlands Elk

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At a glance

Penn Highlands Elk carries a 4-star CMS overall rating — above 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 Limit—Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit—Not available
Central Line Associated Bloodstream Infection: Number of Device Days452Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases0.122Not 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—Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit1.796Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days808Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases1.668Same 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 Limit—Not available
SSI - Colon Surgery: Upper Confidence Limit—Not available
SSI - Colon Surgery: Number of Procedures2Not available
SSI - Colon Surgery: Predicted Cases0.035Not available
SSI - Colon Surgery: Observed Cases0Not 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 Days2561Not available
MRSA Bacteremia: Predicted Cases0.053Not 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 Days2560Not available
Clostridium Difficile (C.Diff): Predicted Cases0.565Not 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 Rate4.3Same as national172
Death rate for heart attack patients—Not available—
Death rate for CABG surgery patients—Not available—
Death rate for COPD patients8.8Same as national38
Death rate for heart failure patients14.1Same as national100
Death rate for pneumonia patients17.7Same as national120
Death rate for stroke patients12.3Same as national32
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-15.5Not available99
Hospital return days for pneumonia patients-23Not available116
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)15Same as national252
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)12.8Same as national332
Rate of inpatient admissions for patients receiving outpatient chemotherapy—Not available—
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy—Not available—
Ratio of unplanned hospital visits after hospital outpatient surgery1Same as national48
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) patients17.6Same as national39
Heart failure (HF) 30-Day Readmission Rate18.8Same as national99
Rate of readmission after hip/knee replacement—Not available—
Pneumonia (PN) 30-Day Readmission Rate14.9Same as national116

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 rating5211
Doctor communication - star rating3211
Communication about medicines - star rating3211
Discharge information - star rating5211
Cleanliness - star rating5211
Quietness - star rating4211
Overall hospital rating - star rating3211
Recommend hospital - star rating3211
Summary star rating4211

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 vaccination88322
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 better198428
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 better190383
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better33822
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better50923
Left before being seen313569
Head CT results——
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients97116
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery——
ST-Segment Elevation Myocardial Infarction (STEMI)——
Safe Use of Opioids - Concurrent Prescribing28166
Appropriate care for severe sepsis and septic shock6045
Septic Shock 3-Hour Bundle——
Septic Shock 6-Hour Bundle——
Severe Sepsis 3-Hour Bundle8746
Severe Sepsis 6-Hour Bundle9733
Discharged on Antithrombotic Therapy10026
Anticoagulation Therapy for Atrial Fibrillation/Flutter——
Antithrombotic Therapy by End of Hospital Day 210025
Venous Thromboembolism Prophylaxis91621
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 Penn Highlands Elk rated?
Penn Highlands Elk has a 4 out of 5 CMS overall star rating as of the latest CMS release.
Does Penn Highlands Elk have emergency services?
Yes. Penn Highlands Elk operates a 24/7 emergency department.
Where is Penn Highlands Elk located?
Penn Highlands Elk is located at 763 Johnsonburg Road, Saint Marys, PA 15857.
What type of hospital is Penn Highlands Elk?
Penn Highlands Elk 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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