HCA Houston Healthcare Southeast
An acute care hospital in Pasadena, Texas 77504
4000 Spencer Hwy, Pasadena, Texas 77504. (713) 359-1000.
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The short answer
Record last released by CMS on Oct 20, 2026.
- 3of 5 CMS’s overall rating
- 2of 5 patient survey rating
- 1 deficiency cited in the last three years
- 481 beds
Each figure’s source sits beside it, in its section below.
What these words mean3
- Star ratings
- CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
The last inspection on record was on Dec 10, 2025: a complaint inspection.
1 deficiency cited in the last three years.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
1 deficiency in 1 month of the last 36. Last cited May 2024. Most serious: Standard-level. The last 3 years, to Nov 5, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Dec | |||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
May 22, 2024: complaint inspection1 deficiency
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Rn Supervision Of Nursing Care
The inspectors’ words, 346 words
“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 23032 Based on interview and record review, the facility failed to ensure that a registered nurses (RN) supervised and evaluated the nursing care for 5 of 8 sampled patients (Patient ID # 1, 2, 3, 4, 8 ). Review of patient skin assessments performed by nursing staff showed several assessments to be missing, incomplete, or inconsistent. Findings included: Review of facility policy titled “Nursing Assessment/Reassessment,” last revised date :08/2022, showed: -H. Each department where nursing care is provided utilizes an interdisciplinary format individualized to the patient population served. Initial Assessment and Reassessment timeframe and criteria for each discipline are outlined in policy Appendix A. Appendix A: Intermediate Care Units : criteria included: head-to-toe systems review; skin and wound assessment; review of systems performed by licensed personnel every shift. ~~~~~~~~~~~~~ On 5/22/2024 on the IMCA unit; 2nd floor, (4) current patient electronic records were reviewed with Staff-F, RN. The review showed the following: - Patient # 1: (four [4] random dates reviewed-both shifts ) : 5 shifts: no skin assessments documented; 1 shift -incomplete skin assessment - Patient # 2 : (three [3 ] random dates reviewed-both shifts ) : 1 shift: documented presence of “skin alteration”: no description of location, type, appearance, etc.. - Patent # 3: (four [4] random dates reviewed-both shifts ) : 2 shifts: no skin assessment documented. - Patent # 4: (four [4 ] random dates reviewed-both shifts ) : 2 shifts: no skin assessment documented; 1 shift: documented presence of “skin alteration”: no description of location, type, appearance, etc.. Patient # 8 ( discharged patient): review of patient skin assessments from 3/8/2024 through 3/22/24 (both shifts) showed inconsistent documentation and description of wounds on Patient # 8’s toe, foot, and sacrum. Multiple shifts lacked documented nursing interventions related to the wounds. On three (3) shifts there was no documented skin assessment. The above findings were verified by Staff-F, RN during the record review”
All 5 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Dec 10, 2025 | Complaint inspection | No deficiencies cited |
| Jul 28, 2025 | Complaint inspection | No deficiencies cited |
| Oct 29, 2024 | Complaint inspection | No deficiencies cited |
| May 22, 2024 | Complaint inspection | 1 deficiency cited |
| Mar 7, 2024 | Complaint inspection | No deficiencies cited |
How do patients fare?
- CMS’s overall CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System. for it is 3 of 5.
- Of the measures behind its CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System., CMS counts against the national value: mortality, 0 better and 0 worse of 7; safety of care, 1 better and 0 worse of 8; readmission, 0 better and 1 worse of 7.
- Patients rate it 2 of 5 in CMS’s patient survey (708 surveys completed, Oct 1, 2024 to Sep 30, 2025): 67% rated it 9 or 10 out of 10, and 64% would definitely recommend it.
- Infections, compared by CMS with the national benchmark (Oct 1, 2024 to Sep 30, 2025): central line bloodstream infections (CLABSI), no different than 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 13.4%, heart failure 12%, pneumonia 15.3%, COPD 8%, stroke 7.8%. 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 15.1%, heart failure 21.1%, pneumonia 17%, COPD 21.6%, heart bypass surgery 11%, hip or knee replacement 6.4%. 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; unplanned hospital visits after outpatient surgery, no different than expected.
- Emergency department patients spent a median of 122 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 1% left before being seen.
- 82% 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 1.11 times the national median (Jan 1, 2024 to Dec 31, 2024).
CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.
CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Overall ratingCMS’s overall hospital quality star rating, 1 to 5 | 3 of 5 |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | 2 of 5 |
Is it certified, and in good standing?
- Medicare-certified acute care hospital since Nov 25, 1968.
- Ownership: proprietary.
- It is accredited by The Joint Commission, whose surveys stand in for the state’s routine inspections.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency on record in the last three years.
- It has an inpatient rehabilitation unit of 31 beds, which CMS lists apart as a rehabilitation facility.
- Proprietary.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Has it been penalized?
- 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.
- 1 deficiency cited in the last three years came from an inspection that included a complaint investigation.
CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
What do patients say about their care?
- CMS doesn’t publish staffing levels for hospitals.
- In CMS’s patient survey, patients rate how well its nurses communicated 2 of 5.
- 52% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.
Who owns it?
- Bayshore Partner, LLC owns 99% directly since Jul 1, 2011.
- 5 owners or officers are people: Eric D Smith (managing employee (under contract)); Steven Scott (corporate officer); Steven Scott (managing employee (on the payroll)); Yasmene Mcdaniel (corporate officer); Yasmene Mcdaniel (managing employee (on the payroll)).
- CMS’s Provider of Services file records 2 changes of ownership, the latest on Jan 1, 2000.
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
| Organisation | Role | Share | Since |
|---|---|---|---|
| HCA Inc. | Owns 5% or more through other companies | 100% | Jul 1, 2011 |
| HCA Healthcare Inc. | Owns 5% or more through other companies | 100% | Jul 1, 2011 |
| Houston Healthcare Holdings, Inc. | Owns 5% or more through other companies | 100% | Jul 1, 2011 |
| Columbia/HCA of Houston, Inc. | Owns 5% or more through other companies | 100% | Jul 1, 2011 |
| Healthtrust Inc. - the Hospital Company | Owns 5% or more through other companies | 100% | Jul 1, 2011 |
| Pasadena Bayshore Hospital, Inc. | Owns 5% or more through other companies | 99% | Jul 1, 2011 |
| Bayshore Partner, LLC | Owns 5% or more directly | 99% | Jul 1, 2011 |
| Hti Hospital Holdings Inc. | Owns 5% or more through other companies | 24.76% | Jul 1, 2011 |
| Women’s Hospital Indianapolis, L.P. | Owns 5% or more through other companies | 18.27% | Jul 1, 2011 |
| Indianapolis Hospital Partner, LLC | Owns 5% or more through other companies | 18.09% | Jul 1, 2011 |
| Frisco Holding II | Owns 5% or more through other companies | 16.3% | Feb 6, 2026 |
| Hercules Holding II | Owns 5% or more through other companies | 14.4% | Feb 6, 2026 |
| HCA Health Services of Texas Inc. | Owns 5% or more through other companies | 10.6% | Jul 1, 2011 |
| Healthserv Acquisition LLC | Owns 5% or more through other companies | 10.6% | Jul 1, 2011 |
| Columbia Hospital Corporation - Delaware | Owns 5% or more through other companies | 6.49% | Jul 1, 2011 |
| Columbia Hospital Corporation of West Houston | Owns 5% or more through other companies | 5.61% | Jul 1, 2011 |
| HCA Squared LLC | Owns 5% or more through other companies | 5.37% | Oct 24, 2011 |
| Hospital Corp LLC | Owns 5% or more through other companies | 5.37% | Jul 1, 2011 |
How does it compare nearby?
- 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 3 of 5.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
What the record doesn’t say
- 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.
Sources
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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).
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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).
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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).
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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).
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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).
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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).
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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).
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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).
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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).
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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).
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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).
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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).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Nov 5, 2026.
From the hospital
The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.