Complications & Deaths Measures
20
CMS-tracked
Pennsylvania · Acute Care
Wellspan Surgery and Rehabilitation Hospital
Wellspan Surgery and Rehabilitation Hospital is a CMS-tracked acute care hospitals in York, PA. CMS has not issued an overall star rating for this facility yet.
- 20
- Quality measures
- 6
- Infection types
Data currency: Hospital quality, safety, and patient-experience measures from the CMS Care Compare program (published quarterly), last refreshed May 2026. See our methodology for source dates. Spot a figure that looks wrong? Report a correction.
55 Monument Road, York, PA 17403 · York County · (717) 812-6100
The verdict
Wellspan Surgery and Rehabilitation Hospital is Medicare-certified but has no CMS overall star rating yet, typically a sign its reporting volumes fell below CMS thresholds during the latest measurement window. 20 individual quality measures are still on file.
- 1
- measures better than national of 4 compared
- No
- emergency department on site
Type
Acute Care Hospitals
Ownership
Voluntary non-profit - Private
Emergency Services
No
Birthing Friendly
N/A
Patient Experience
17
HCAHPS domains
Infection Types
6
CDC NHSN
Better-than-national profile for Wellspan Surgery and Rehabilitation Hospital
Mortality 1 measure
Safety of care 1 measure
Readmission 2 measures
Better than national Same as national Worse than national
Quality Measures
| Measure | Score | vs. National |
|---|---|---|
| Abdominopelvic accidental puncture or laceration rate | 1.06 | Same as National |
| CMS Medicare PSI 90: Patient safety and adverse events composite | 0.96 | Same as National |
| Death rate among surgical inpatients with serious treatable complications | N/A | Not Available |
| Death rate for CABG surgery patients | N/A | Not Available |
| Death rate for COPD patients | N/A | Not Available |
| Death rate for heart attack patients | N/A | Not Available |
| Death rate for heart failure patients | N/A | Not Available |
| Death rate for pneumonia patients | N/A | Not Available |
| Death rate for stroke patients | N/A | Not Available |
| Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate | 4.1 | Same as National |
| Iatrogenic pneumothorax rate | 0.21 | Same as National |
| In-hospital fall-associated fracture rate | 0.27 | Same as National |
| Perioperative pulmonary embolism or deep vein thrombosis rate | 3.36 | Same as National |
| Postoperative acute kidney injury requiring dialysis rate | 1.66 | Same as National |
| Postoperative hemorrhage or hematoma rate | 2.28 | Same as National |
Patient Experience (HCAHPS)
Experience profile vs. the national average
Source: CMS Hospital Compare, HCAHPS patient survey star ratings.
| Survey Question | Star Rating |
|---|---|
| Cleanliness - linear mean score | N/A |
| Cleanliness - star rating | 3 |
| Communication about medicines - linear mean score | N/A |
| Communication about medicines - star rating | 3 |
| Discharge information - linear mean score | N/A |
| Discharge information - star rating | 5 |
| Doctor communication - linear mean score | N/A |
| Doctor communication - star rating | 3 |
| Nurse communication - linear mean score | N/A |
| Nurse communication - star rating | 5 |
| Overall hospital rating - linear mean score | N/A |
| Overall hospital rating - star rating | 5 |
| Quietness - linear mean score | N/A |
| Quietness - star rating | 5 |
| Recommend hospital - linear mean score | N/A |
| Recommend hospital - star rating | 5 |
| Summary star rating | 4 |
Safety & Infections
| Measure | Score | vs. National |
|---|---|---|
| Catheter Associated Urinary Tract Infections (ICU + select Wards) | N/A | Not Available |
| Central Line Associated Bloodstream Infection (ICU + select Wards) | N/A | Not Available |
| Clostridium Difficile (C.Diff) | N/A | Not Available |
| MRSA Bacteremia | N/A | Not Available |
| SSI - Abdominal Hysterectomy | N/A | Not Available |
| SSI - Colon Surgery | N/A | Not Available |
Staffing & Spending
Unplanned Visits & Readmissions
| Measure | Score | vs. National |
|---|---|---|
| Acute Myocardial Infarction (AMI) 30-Day Readmission Rate | N/A | Number of Cases Too Small |
| Heart failure (HF) 30-Day Readmission Rate | N/A | Number of Cases Too Small |
| Hospital return days for heart attack patients | N/A | Number of Cases Too Small |
| Hospital return days for heart failure patients | N/A | Number of Cases Too Small |
| Hospital return days for pneumonia patients | N/A | Number of Cases Too Small |
| Hybrid Hospital-Wide All-Cause Readmission Measure (HWR) | 15.5 | Same as National |
| Pneumonia (PN) 30-Day Readmission Rate | N/A | Number of Cases Too Small |
| Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy | N/A | Not Available |
| Rate of inpatient admissions for patients receiving outpatient chemotherapy | N/A | Not Available |
| Rate of readmission after hip/knee replacement | N/A | Number of Cases Too Small |
| Rate of readmission for CABG | N/A | Not Available |
| Rate of readmission for chronic obstructive pulmonary disease (COPD) patients | N/A | Number of Cases Too Small |
| Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies) | N/A | Not Available |
| Ratio of unplanned hospital visits after hospital outpatient surgery | 0.8 | Same as National |
Medicare Spending
| Measure | Score |
|---|---|
| Medicare hospital spending per patient (Medicare Spending per Beneficiary) | 1.09 |
Maternal Health
| Measure | Score |
|---|---|
| Cesarean Birth | N/A |
| Maternal Morbidity Structural Measure | N/A |
| Risk Adjusted Severe Obstetric Complications (All) | N/A |
| Risk Adjusted Severe Obstetric Complications (excluding blood-transfusion-only cases) | N/A |
Nationwide hospitals with similar CMS profiles
Peer sets for Wellspan Surgery and Rehabilitation Hospital outside Pennsylvania, keyed to the strong better-than-national share.
Similar mortality outcomes
Nearest mortality measures rated better than national, outside PA (0 better here).
Nearby Hospitals in Pennsylvania
Other Medicare-certified hospitals in Pennsylvania.
One of 186 Medicare-certified hospitals in Pennsylvania, 6 are shown here.
Acmh Hospital
Kittanning, PA
3/5
Acute Care Hospitals
Advanced Surgical Hospital
Washington, PA
No rating Acute Care Hospitals
Ahn Emerus Westmoreland, LLC
Greensburg, PA
No rating Acute Care Hospitals
Ahn Wexford Hospital
Wexford, PA
5/5
Acute Care Hospitals
Allegheny General Hospital
Pittsburgh, PA
3/5
Acute Care Hospitals
Allegheny Valley Hospital
Natrona, PA
4/5
Acute Care Hospitals
Compare Wellspan Surgery and Rehabilitation Hospital vs Acmh Hospital →
Frequently Asked Questions
How does Wellspan Surgery and Rehabilitation Hospital compare to other hospitals on CMS star rating?
Wellspan Surgery and Rehabilitation Hospital has no CMS overall star rating, so it is excluded from the rated-hospital corpus placement (unrated).
What is the CMS star rating for Wellspan Surgery and Rehabilitation Hospital?
Wellspan Surgery and Rehabilitation Hospital does not currently have a CMS star rating, typically because reporting volumes fell below CMS's calculation threshold.
How does Wellspan Surgery and Rehabilitation Hospital perform on quality measures?
1 of 4 compared mortality, safety, and readmission measures rate better than the national average at Wellspan Surgery and Rehabilitation Hospital (strong better-share tercile); 0 rate worse (typical).
What do patients say about Wellspan Surgery and Rehabilitation Hospital?
Wellspan Surgery and Rehabilitation Hospital reports 17 HCAHPS patient-experience domain scores. Star ratings range from 3 to 5 out of 5.
What are the infection rates at Wellspan Surgery and Rehabilitation Hospital?
Wellspan Surgery and Rehabilitation Hospital tracks 6 healthcare-associated infection types (CDC NHSN). 0 are better than the national benchmark, 0 are worse, and 0 are at the national average.
Does Wellspan Surgery and Rehabilitation Hospital have emergency services?
No, Wellspan Surgery and Rehabilitation Hospital does not provide emergency services. For emergencies, seek care at a nearby facility with an emergency department.
What type of hospital is Wellspan Surgery and Rehabilitation Hospital?
Wellspan Surgery and Rehabilitation Hospital is a Acute Care Hospitals facility with Voluntary non-profit - Private ownership, located in York, PA.
How much does Medicare spend at Wellspan Surgery and Rehabilitation Hospital?
1 Medicare spending category is on file for Wellspan Surgery and Rehabilitation Hospital, per episode vs. the national median.
Does Wellspan Surgery and Rehabilitation Hospital offer maternal health services?
Yes, Wellspan Surgery and Rehabilitation Hospital reports 4 maternal health measures.
Read our methodology & full data source list · Source: CMS Hospital Compare · measure windows