JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Other

Wellspan Ephrata Community Hospital

5 / 5

At a glance

Wellspan Ephrata Community Hospital carries a 5-star CMS overall rating — above the national norm. For 30-day readmissions, it beats the national rate on 2 measures and trails 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 Limit1.954Same as national
Central Line Associated Bloodstream Infection: Number of Device Days2179Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases1.533Same 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 Limit0.025Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit2.475Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days2716Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases1.993Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases1Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.502Same as national
SSI - Colon Surgery: Lower Confidence Limit0.448Same as national
SSI - Colon Surgery: Upper Confidence Limit4.794Same as national
SSI - Colon Surgery: Number of Procedures69Same as national
SSI - Colon Surgery: Predicted Cases1.703Same as national
SSI - Colon Surgery: Observed Cases3Same as national
SSI - Colon Surgery1.762Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures32Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.270Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitSame as national
MRSA Bacteremia: Upper Confidence Limit2.684Same as national
MRSA Bacteremia: Patient Days26644Same as national
MRSA Bacteremia: Predicted Cases1.116Same as national
MRSA Bacteremia: Observed Cases0Same as national
MRSA Bacteremia0.000Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.314Same as national
Clostridium Difficile (C.Diff): Upper Confidence Limit1.418Same as national
Clostridium Difficile (C.Diff): Patient Days24601Same as national
Clostridium Difficile (C.Diff): Predicted Cases9.764Same as national
Clostridium Difficile (C.Diff): Observed Cases7Same as national
Clostridium Difficile (C.Diff)0.717Same 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 patientsNot available
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate3.8Same as national760
Death rate for heart attack patients11.6Same as national120
Death rate for CABG surgery patientsNot available
Death rate for COPD patients9.4Same as national28
Death rate for heart failure patients10.1Same as national257
Death rate for pneumonia patients16.8Same as national132
Death rate for stroke patients11.3Same as national121
Pressure ulcer rate0.29Same as national2292
Death rate among surgical inpatients with serious treatable complications152.44Same as national26
Iatrogenic pneumothorax rate0.18Same as national2815
In-hospital fall-associated fracture rate0.24Same as national2813
Postoperative hemorrhage or hematoma rate2.61Same as national597
Postoperative acute kidney injury requiring dialysis rate1.59Same as national232
Postoperative respiratory failure rate9.03Same as national213
Perioperative pulmonary embolism or deep vein thrombosis rate3.08Same as national626
Postoperative sepsis rate6.12Same as national213
Postoperative wound dehiscence rate2.01Same as national143
Abdominopelvic accidental puncture or laceration rate0.94Same as national412
CMS Medicare PSI 90: Patient safety and adverse events composite0.89Same 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 patients-25.3Not available94
Hospital return days for heart failure patients-47.8Not available277
Hospital return days for pneumonia patients0.6Not available133
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)13.5Better than national1148
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)13.7Same as national233
Rate of inpatient admissions for patients receiving outpatient chemotherapy11.1Same as national53
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy4.8Same as national53
Ratio of unplanned hospital visits after hospital outpatient surgery0.9Same as national374
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate12.4Same as national94
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients18.5Same as national30
Heart failure (HF) 30-Day Readmission Rate16.5Better than national277
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate15.6Same as national133

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 rating4457
Doctor communication - star rating3457
Communication about medicines - star rating2457
Discharge information - star rating4457
Cleanliness - star rating2457
Quietness - star rating2457
Overall hospital rating - star rating3457
Recommend hospital - star rating3457
Summary star rating3457

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 vaccination961266
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 better199379
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 better190342
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better31226
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better48711
Left before being seen129800
Head CT results
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients100118
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)6144
Safe Use of Opioids - Concurrent Prescribing181243
Appropriate care for severe sepsis and septic shock69188
Septic Shock 3-Hour Bundle6641
Septic Shock 6-Hour Bundle8222
Severe Sepsis 3-Hour Bundle79188
Severe Sepsis 6-Hour Bundle9989
Discharged on Antithrombotic Therapy98115
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 29593
Venous Thromboembolism Prophylaxis
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 MeasureYes

Frequently asked questions

How is Wellspan Ephrata Community Hospital rated?
Wellspan Ephrata Community Hospital has a 5 out of 5 CMS overall star rating as of the latest CMS release.
Does Wellspan Ephrata Community Hospital have emergency services?
Yes. Wellspan Ephrata Community Hospital operates a 24/7 emergency department.
Where is Wellspan Ephrata Community Hospital located?
Wellspan Ephrata Community Hospital is located at 169 Martin Avenue, Ephrata, PA 17522.
What type of hospital is Wellspan Ephrata Community Hospital?
Wellspan Ephrata Community Hospital is classified by CMS as a Acute Care Hospitals facility (Voluntary non-profit - Other).

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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