Hearth Record

Memorial Hermann Memorial City Hospital

An acute care hospital in Houston, Texas 77024

921 Gessner, Houston, Texas 77024. (713) 242-3000.

CMS’s own record, on Care Compare

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The short answer

Record last released by CMS on Oct 20, 2026.

The last 24 months 4 deficiencies in 3 months of the last 36. Last cited Jan 2026. Most serious: Standard-level. Every month

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 Jun 24, 2026: a complaint inspection.

4 deficiencies cited in the last three years, 1 of them under EMTALA, the law requiring an emergency department to examine and stabilise anyone who comes to it.

Source:

CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.

When those deficiencies happened

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

4 deficiencies by month over the last 3 years. Each cell is one month.
JanFebMarAprMayJunJulAugSepOctNovDec
2023 Dec
2024 JanFebMarAprMayJunJulAugSepOctNovDec
2025 JanFebMarAprMayJunJulAugSepOctNovDec
2026 JanFebMarAprMayJunJulAugSepOctNov

Hover or focus a month to read it.

No visit on record Visited, nothing cited A stronger orange is more serious, on its source’s own levels, read onto four bands: from the least serious it publishes to the most
Source:

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.

Source:

CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.

Jan 2, 2026: complaint inspection1 deficiency

  • Emergency Room Log

    The inspectors’ words, 328 words

    “EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 23032 Based on record review and interview, the facility failed to maintain an accurate Emergency Room Log. The Emergency Room Log showed an inaccurate disposition for 3 of 24 sampled patients reviewed (Patient ID # 13, 14, 24). Findings included: Review of facility policy titled” Patient Transfer Policy (EMTALA and Texas Transfer Act Compliance, last review date 03/29/2023, showed: “B. 5. Emergency Room Log: The Hospital shall maintain a central log on each individual who comes to the Emergency Department seeking assistance and whether the individual refused treatment, was refused treatment, was transferred, was admitted to the Hospital and treated, was stabilized and transferred, or was discharged.” Review of facility Emergency Room Log and ED clinical records with Staff #55, ED RN, showed the following: -Patient ID #13 : Emergency Room Log , dated 11/29/2025, listed patient’s disposition as “discharged”. Review of his ED clinical record record showed he was admitted to the hospital. -Patient ID #14 : Emergency Room Log , dated 7/19/2025, listed patient’s disposition as “discharged”. Review of her ED clinical record record showed she was admitted to the hospital. -Patient ID #24: Emergency Room Log , dated 8//31/2025, listed patient’s disposition as “Medical Screening Exam [MSE] (screened & referred)”. Review of his ED clinical record record showed he Left Before Treatment Complete (LBTC). The above findings were verified by Staff ID # 55 at the time of review.”

    Rule A2405. Standard-level. From a complaint.

Apr 24, 2024: complaint inspection1 deficiency

  • Rn Supervision Of Nursing Care

    The inspectors’ words, 314 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 an RN evaluated the care of each patient. Nursing staff failed to perform a pain reassessment after administering intravenous (IV) pain medication to 2 of 2 sampled patients [ Patient # 5, 6]. Findings included: Review of facility policy titled “ Pain Assessment and Management,” dated 10/03/2022, showed : Purpose: patients have the right to have their pain assessed and appropriately managed.... H, Interventions: 4. Monitor, reassess, and document the effectiveness of pharmacological and non-pharmacological interventions in Pain Assessment Electronic Medication Administration Record (eMar) ...at the following intervals: b. IV medications: ADULTS: 30-60 minutes ( 0.5- 1 hour) after administration. Record review of 2 current patient medical records on 4/24/2024 on 7 M Tower with Staff -F, RN, showed the following: Patient ID # 5 was administered a scheduled dose of IV Dilaudid 1 milligram (mg) for pain management on 4/22/2024 at 1858. Patient # 5’s pain was assessed as 7 / 10 prior to being given the drug. Her pain was not reassessed after the administration of the IV Dilaudid. Patient ID # 6 was administered a PRN ( as needed ) dose of IV Dilaudid 2 mg for pain management on 4/18/2024 at 1205. Patient # 6’s pain was assessed as 7 / 10 prior to being given the drug. Her pain was not reassessed after the administration of the IV Dilaudid. During an interview on 4/24//2024 at 1:15 PM with Staff-F, RN, she stated that patients should be reassessed for effectiveness of the IV pain medication within 30 to 60 minutes after it was given. Staff-F said this was true for both scheduled and PRN does of IV pain medication.”

    Rule A0395. Standard-level. From a complaint.

Feb 29, 2024: complaint inspection2 deficiencies

  • Patient Rights: Review Of Grievances

    The inspectors’ words, 303 words

    “PATIENT RIGHTS: REVIEW OF GRIEVANCES CFR(s): 482.13(a)(2) [The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.] The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. This Standard is not met as evidenced by: 37490 Based on record review and interview, facility failed to ensure an effective process for resolving grievances. The facility failed to fully investigate patient’s grievance in 1 of 3 patients (ID # 1). Findings include: Record of facility policy and procedure titled “Patient Complaints and Grievances” dated 6/3/2022 showed the following information: DEFINITIONS: A “patient grievance” is a formal or informal written or verbal complaint that is made to the health care system by a patient, or patient’s representative, regarding the patient’s care) when the complaint is not resolved at the time of the complaint by staff present) ... POLICY STATEMENT: 4. Grievancees are incorporated into performance improvement and patient safety activities. PROCEDURE: ACTION: 7.Department leadership will investigate the grievance including, as appropriate, clinical reviews and staff interviews. 8. Document findings in hospital approved electronic tracking tool or send results to patient relations team ... Review of patient relations worksheet for patient (ID# 1) Synopsis-included but not limited to the patient stating that they are allergic to specific suture that was used during her surgery. Grievance was closed with no documented investigation regarding suture usage in the opeating room. Interview with patient relations staff (ID# 72) on 2/29/2024 at 1:45 PM, she confirmed the above findings. Interview with facility CMO (ID# 54) on 2/29/2024 at 1:08 PM confirmed the above findings, stating that there some gaps in this grievance investigation/process.”

    Rule A0119. Standard-level. From a complaint.

  • Post-Anesthesia Evaluation

    The inspectors’ words, 482 words

    “POST-ANESTHESIA EVALUATION CFR(s): 482.52(b)(3) [The policies must ensure that the following are provided for each patient:] A post-anesthesia evaluation completed and documented by an individual qualified to administer anesthesia, as specified in paragraph (a) of this section, no later than 48 hours after surgery or a procedure requiring anesthesia services. The post-anesthesia evaluation for anesthesia recovery must be completed in accordance with State law and with hospital policies and procedures, which have been approved by the medical staff and which reflect current standards of anesthesia care. This Standard is not met as evidenced by: 37490 Based on record review, and interview, the facility failed to ensure 2 of 3 patients received post anesthesia assessments prior to discharge from the post anesthesia care unit (PACU) due to inconsistent process (ID#s 10 and 12). Findings include: Record review of facility Rules and Regulations for the Medical Staff showed the following information: L. The Anesthesiologist The anesthesiologist shall maintain a complete anesthesia record to include evidence of pre-anesthetic evaluation and post-anesthetic evaluation follow-up of the patient’s condition. Medical record review for patients (ID#s 10 and 12) on 2/29/24 at 9:25 AM for date of service 2/28/2024 showed no completed post anesthesia assessment. Interview with perioperative services manger (ID# 62) on 2/29/24 at 9:25 AM, she confirmed the above findings and stated that patients are to receive a post anesthesia assessment prior to being discharged from the PACU. Interview with anesthesiologist (ID #66) on 2/29/24 at 9:30 AM, he stated that the post anesthesia assessment is to be completed on the paper anesthesia form. Interview with chief of anesthesia (ID# 67) on 2.29/24 at 9:45 AM, she stated that the post anesthesia assessment is usually completed on the paper form but providers could also document in the computer. No evidence of computer documentation of post anesthesia assessment was provided while surveyor was on site. Interview with staff RN (ID# 63) on 2/29/24 at 9:50 AM, she stated that when patients meet criteria, they are moved to phase II PACU and are discharged from there. The vital signs are documented on the anesthesia assessment sheet but we do not wait for them to get signed before moving the patient. The anesthesia paper is kept to be signed by the anesthesia person to sign as they periodically are coming through checking on patients. Interview with staff RN (ID# 64) on 2/29/23 at 9:53 PM, she stated that patients are moved to Phase II when criteria is met. Anesthesia will see them at some point before they are discharged. Interview with staff RN (ID# 65) on 2/29/24 at 9:55 stated that she is not sure when anesthesia will get back around to see patients in PACU as they may be busy in pre-op. She stated that when patient criteria is met, they go to the next phase. If there is an issue with their condition we can call anesthesia.”

    Rule A1005. Standard-level. From a complaint.

All 6 inspections in the last three years
Inspections on record
DateVisitWhat the record says
Jun 24, 2026Complaint inspectionNo deficiencies cited
Jan 2, 2026Complaint inspection1 deficiency cited
Jul 22, 2025Complaint inspectionNo deficiencies cited
Apr 24, 2024Complaint inspection1 deficiency cited
Feb 29, 2024Complaint inspection2 deficiencies cited
Dec 15, 2023Complaint inspectionNo deficiencies cited

How do patients fare?

  • CMS’s overall for it is 4 of 5.
  • Of the measures behind its , CMS counts against the national value: mortality, 2 better and 0 worse of 8; safety of care, 3 better and 0 worse of 7; readmission, 1 better and 0 worse of 8.
  • Patients rate it 3 of 5 in CMS’s patient survey (902 surveys completed, Oct 1, 2024 to Sep 30, 2025): 70% 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), 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 14.4%, heart failure 8.1%, pneumonia 13.2%, COPD 8.7%, stroke 9.2%, heart bypass surgery 1.9%. 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 14.4%, heart failure 21.3%, pneumonia 16.3%, COPD 18.3%, heart bypass surgery 10%, hip or knee replacement 6.3%. 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 259 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 1% left before being seen.
  • 41% 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 times the national median (Jan 1, 2024 to Dec 31, 2024).
Source:

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.

Ratings and measures, as published
MeasureRating
Overall ratingCMS’s overall hospital quality star rating, 1 to 54 of 5
Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 53 of 5

Is it certified, and in good standing?

  • Medicare-certified acute care hospital since Aug 17, 1971.
  • Ownership: voluntary non-profit - private.
  • It is accredited by The Joint Commission, whose surveys stand in for the state’s routine inspections.
  • No deficiency on record in the last three years.
  • Voluntary non-profit - Private.
Source:

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.
  • 4 deficiencies cited in the last three years came from inspections that included a complaint investigation.
Source:

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.
  • 94% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
Source:

CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.

Who owns it?

  • Memorial Hermann Health System owns 100% directly since Jan 1, 2010.
  • Memorial Hermann Health System runs it.
  • 33 owners or officers are people: Greg Armstrong (corporate director, 0%); Rishi Varma (other role (CMS gives no detail), 0%); Monica Benton (corporate director, 0%); Richard Figueroa (corporate director); Paul O’sullivan (managing employee (on the payroll), 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 (corporate director); Jay F Schneider (other role (CMS gives no detail), 0%); David Habachy (other role (CMS gives no detail), 0%); John Esquivel (corporate director, 0%); Alan Victor Ytterberg (corporate director); 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 (corporate director, 0%); Caralisa M Simon (other role (CMS gives no detail), 0%); Alec King (corporate officer, 0%); Christophe C Salcedo (corporate director); 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 2 changes of ownership.
  • No private-equity firm among the owners CMS lists.
  • No real-estate investment trust among the owners CMS lists.
Source:

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.

Organisations CMS lists
OrganisationRoleShareSince
Memorial Hermann Health SystemOwns 5% or more directly100%Jan 1, 2010
Memorial Hermann Health SystemRuns it (operational or managerial control)100%Jan 1, 2013

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 4 of 5.
Source:

CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.

12 compared
PlaceOverall star rating
St Joseph Medical Center3
Memorial Hermann - Texas Medical Center4
HCA Houston Healthcare Southeast3
Memorial Hermann Hospital System3
Baylor St Lukes Medical Center4
Harris Health3
Houston Methodist Hospital5
Houston Methodist Baytown Hospital5
HCA Houston Healthcare Clear Lake4
HCA Houston Healthcare Northwest2
HCA Houston Healthcare West1
HCA Houston Healthcare Medical Center4

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

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.

Source:

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.

How to read a record

Four things every record does, shown on an example record made up for this guide.

An example record, made up for this guide

An example nursing home

Made up for this guide: no real place is shown

Not fully inspected in over two years (CMS flag)

11 health citations at the latest inspection cycle

The state average is 14.3.

Source:

CMS, State and US Averages and Health Deficiencies. Released Oct 28, 2026. Updated monthly.

From the homeNone yet. Replies and paid listings aren’t open, and when they open they will sit here, below the record.

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