Memorial Hermann - Texas Medical Center

When those deficiencies happened

2 deficiencies in 1 month of the last 36. Last cited Jan 2024. Most serious: Standard-level. The last 3 years, to Nov 5, 2026.

Each deficiency, as cited

Rule titles as CMS’s inspectors cite them, set in sentence case.

• CMS’s overall star rating: what this means for it is 4 of 5.
• Of the measures behind its star rating: what this means, CMS counts against the national value: mortality, 1 better and 0 worse of 8; safety of care, 4 better and 0 worse of 7; readmission, 2 better and 2 worse of 10.
• Patients rate it 3 of 5 in CMS’s patient survey (2,509 surveys completed, Oct 1, 2024 to Sep 30, 2025): 72% rated it 9 or 10 out of 10, and 71% would definitely recommend it.
• Infections, compared by CMS with the national benchmark (Oct 1, 2024 to Sep 30, 2025): central line bloodstream infections (CLABSI), better than the national benchmark; catheter urinary tract infections (CAUTI), better than the national benchmark; surgical site infections after colon surgery, no different than national benchmark; surgical site infections after abdominal hysterectomy, no different than national benchmark; MRSA bloodstream infections, no different than national benchmark; C. diff infections, better than the national benchmark.
• CMS’s patient safety composite for serious complications, PSI 90, Jul 1, 2022 to Jun 30, 2024: no different than the national value.
• Deaths within 30 days, as CMS gives them (Jul 1, 2022 to Jun 30, 2025): heart attack 12.3%, heart failure 8.2%, pneumonia 12.3%, COPD 12.3%, stroke 9.6%, heart bypass surgery 2.9%. CMS gives no comparison with the national rate for them in this release.
• Readmissions within 30 days, as CMS gives them (Jul 1, 2023 to Jun 30, 2025): heart attack 14%, heart failure 21.4%, pneumonia 17.2%, COPD 20.2%, heart bypass surgery 9.9%, hip or knee replacement 5.6%. CMS gives no comparison with the national rate for them in this release.
• After outpatient care, compared by CMS: unplanned hospital visits after a colonoscopy, no different than the national rate; hospital admissions after outpatient chemotherapy, no different than the national rate; emergency visits after outpatient chemotherapy, no different than the national rate; unplanned hospital visits after outpatient surgery, no different than expected.
• Emergency department patients spent a median of 252 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 5% left before being seen.
• 39% of patients with severe sepsis or septic shock got the care CMS measures, SEP-1 (Oct 1, 2024 to Sep 30, 2025).
• Medicare’s spending per patient here is 1.03 times the national median (Jan 1, 2024 to Dec 31, 2024).

• Medicare-certified acute care hospital since Jul 1, 1966.
• Ownership: voluntary non-profit - private.
• It is accredited by The Joint Commission, whose surveys stand in for the state’s routine inspections.
• No condition-level: what this means deficiency on record in the last three years.
• It has an inpatient rehabilitation unit of 22 beds, which CMS lists apart as a rehabilitation facility.
• Voluntary non-profit - Private.

• CMS doesn’t publish fines or other penalties for hospitals.
• Not among the hospitals whose Medicare payments CMS cut under the Hospital-Acquired Condition Reduction Program for fiscal year 2026.
• 2 deficiencies cited in the last three years came from inspections that included a complaint investigation.

• CMS doesn’t publish staffing levels for hospitals.
• In CMS’s patient survey, patients rate how well its nurses communicated 3 of 5.
• 95% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).

• Memorial Hermann Health System owns 100% directly since Jan 1, 2013.
• Memorial Hermann Health System runs it.
• 30 owners or officers are people: Greg Armstrong (other role (CMS gives no detail), 0%); Rishi Varma (other role (CMS gives no detail), 0%); Monica Benton (other role (CMS gives no detail), 0%); Richard Figueroa (other role (CMS gives no detail), 0%); Theresa Ancelet Pappas (corporate officer, 0%); Sara Ortwein (other role (CMS gives no detail), 0%); John A. Graf (other role (CMS gives no detail), 0%); Jarvis Hollingsworth (other role (CMS gives no detail), 0%); Jay F Schneider (other role (CMS gives no detail), 0%); David Habachy (other role (CMS gives no detail), 0%); John Esquivel (other role (CMS gives no detail), 0%); Alan Victor Ytterberg (corporate director, 0%); Neelofer S Durrani (other role (CMS gives no detail), 0%); Anne Taylor (corporate director, 0%); Max Reynolds (corporate officer, 0%); Max Reynolds (managing employee (on the payroll), 0%); Ira L Flax (other role (CMS gives no detail), 0%); Charmaine Ferguson (managing employee (on the payroll), 0%); Aileen Mccormick (other role (CMS gives no detail), 0%); Edward Adams (other role (CMS gives no detail), 0%); Caralisa M Simon (other role (CMS gives no detail), 0%); Harry Pefanis (other role (CMS gives no detail), 0%); Gary J Sheppard (corporate director, 0%); Kevin Brady (other role (CMS gives no detail), 0%); Alejandra Loessin (corporate officer, 0%); Anne Clutterbuck (other role (CMS gives no detail), 0%); Donald M Woo (other role (CMS gives no detail), 0%); David L Callender (corporate officer, 0%); David L Callender (managing employee (on the payroll), 0%); Willoughby C Williams (other role (CMS gives no detail), 0%).
• CMS’s Provider of Services file records 1 change of ownership, the latest on Nov 4, 1997.
• No private-equity firm among the owners CMS lists.
• No real-estate investment trust among the owners CMS lists.

• Of the 50 hospitals CMS lists in Harris County, 23 have an overall star rating from CMS: 6 rated 5 of 5, 7 rated 4 of 5, 8 rated 3 of 5, 1 rated 2 of 5, 1 rated 1 of 5.
• CMS rates this one 4 of 5.

• CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
• Only complaints that led to a citation appear; complaints that didn’t aren’t published.
• Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
• QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
• CMS doesn’t publish staffing levels for hospitals.
• In its September 2026 release CMS gives no comparison with the national rate for death and readmission rates, though it gives the rates.

• Centers for Medicare & Medicaid Services, Hospital General Information (xubh-q36u).

  Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).

• Centers for Medicare & Medicaid Services, Patient survey (HCAHPS) - Hospital.

  Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).

• Centers for Medicare & Medicaid Services, Healthcare Associated Infections - Hospital (77hc-ibv8).

  Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).

• Centers for Medicare & Medicaid Services, Complications and Deaths - Hospital (ynj2-r877).

  Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).

• Centers for Medicare & Medicaid Services, Unplanned Hospital Visits - Hospital (632h-zaca).

  Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).

• Centers for Medicare & Medicaid Services, Timely and Effective Care - Hospital (yv7e-xc69).

  Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).

• Centers for Medicare & Medicaid Services, Medicare Spending Per Beneficiary - Hospital (rrqw-56er).

  Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).

• Centers for Medicare & Medicaid Services, Hospital-Acquired Condition (HAC) Reduction Program (yq43-i98g).

  Released Aug 13, 2026 and checked Nov 5, 2026. Updated yearly. Public domain (U.S. Government work).

• Centers for Medicare & Medicaid Services, Provider of Services File - Hospital & Non-Hospital Facilities (Hospital_and_other.DATA.Q3_2026.csv).

  Released Oct 14, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).

• Centers for Medicare & Medicaid Services, QCOR Hospital 2567 statements of deficiencies (Hospital_2567s_2010_to_2026YTD.xlsx).

  Released Oct 20, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).

• Centers for Medicare & Medicaid Services, Hospital All Owners (Hospital_All_Owners_2026.09.29.csv).

  Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).

• Centers for Medicare & Medicaid Services, Hospital Enrollments (Hospital_Enrollments_2026.09.29.csv).

  Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).

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