HCA Houston Healthcare West
An acute care hospital in Houston, Texas 77082
12141 Richmond Ave, Houston, Texas 77082. (281) 588-8080.
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The short answer
Record last released by CMS on Oct 20, 2026.
- 1of 5 CMS’s overall rating
- 2of 5 patient survey rating
- 1 deficiency cited in the last three years
- 302 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 Apr 16, 2026: 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 Feb 2025. 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.
Feb 25, 2025: complaint inspection1 deficiency
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Medical Record Services
The inspectors’ words, 647 words
“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 46010 Based on interview and record review, the facility failed to ensure that medical record entries were complete and accurate. The facility failed to ensure that medical records for Patient ID #s 10-34, who sought care through the Emergency Department between January 17, 2024 through February 17, 2025, had the correct Emergency Department attending physician, who provided care, listed as the Emergency Department physician of record (Patient ID #s 10-34). Findings included: Record review of Physician Staff ID # 76 credentialing file with Director of Medical Staff ID # 63 on 2/25/25 at 10:45 am revealed physician staff ID #76 was credentialed through the facility’s regional credentialing office and granted privileges on 1/14/24. Record review of ED Provider schedule from 1/1/24 to 2/25/2025 with Director of Medical Staff ID #63 on 2/25/25 at 10:50 am revealed Physician Staff ID #76 had not been scheduled for any shifts at the facility ever. Record review of Medical Record Provider report for Physician Staff ID #76 titled “Physician Statistics” for dates 1/1/24 through 2/25/25 provided by Director of HIM Staff ID # 53 revealed that 35 patient records had been assigned to Physician Staff ID # 76 for signature at different points after the patients arrived to seek care in the facility’s main ED. Director of Clinical Informatics Staff ID #58 confirmed that the attending MD could be assigned through registration process by business office representatives, by the nurse who started encounter, by the physician when they were “signing up for the patient” or forwarded by an advanced practice provider for attending physician co-signature after they saw a patient in the ED. She confirmed there was no audit process in place by the medical records department to ensure that records had been sent to the correct provider for signature. Record review of facility policy titled “General Record Information”, effective 11/2023, stated “Procedure 1. Purposes of the medical record: a. To document the hospitalization and care rendered. B. To serve as a means of communication between the physician and other healthcare professionals caring for the patient ....d. to ensure the delivery of quality patient care.” It further stated “16. Legibility: All entries in the medical record must be legible and complete, and must be authenticated by the person making the entry in the medical record.” Interview with Director of Clinical Informatics HIM Staff ID #58 on 2/25/25 at 11:50 am, she confirmed that the Meditech medical record system does not allow physicians to refuse signatures on ED notes which are routed to the wrong provider. She stated it requires the forwarding provider to retract and resend the medical record to the correct provider. She confirmed that the Meditech electronic medical record system reflected that physician staff ID #76 was the attending ED provider for patient ID #s 10-34. She confirmed that all charts had notes which were ultimately routed to other providers for final signatures. She confirmed that the medical record should have the treating ED physician listed as the ED attending physician in the medical record. Interview with Director of HIM Staff ID #53 on 2/25/25 at 10:45 am. She confirmed that the facility does not have a process for identifying discrepancies between physician of record and the responsible physician who signed the medical record. She confirmed the processes currently in place were to ensure compliance with the chart closure timeline within 30 days. She described this as meaning that all pending or open orders and notes had to be completed. She confirmed there was no process for ensuring that providers who had same last names were be routed the correct charts.”
All 6 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Apr 16, 2026 | Complaint inspection | No deficiencies cited |
| Jan 8, 2026 | Complaint inspection | No deficiencies cited |
| Feb 25, 2025 | Complaint inspection | 1 deficiency cited |
| Jan 24, 2025 | Complaint inspection | No deficiencies cited |
| Aug 16, 2024 | Complaint inspection | No deficiencies cited |
| Feb 14, 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 1 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 6; safety of care, 1 better and 0 worse of 6; readmission, 0 better and 2 worse of 5.
- Patients rate it 2 of 5 in CMS’s patient survey (714 surveys completed, Oct 1, 2024 to Sep 30, 2025): 59% rated it 9 or 10 out of 10, and 56% 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; 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 11.2%, heart failure 8.8%, pneumonia 13.3%, stroke 11.7%. 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 15.4%, heart failure 21%, pneumonia 16.9%, COPD 19%, heart bypass surgery 11.8%. CMS gives no comparison with the national rate for them in this release.
- After outpatient care, compared by CMS: unplanned hospital visits after outpatient surgery, no different than expected.
- Emergency department patients spent a median of 104 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 1% left before being seen.
- 67% 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).
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 | 1 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 Jun 2, 1974.
- 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 12 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.
- 33% 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?
- West Houston LLC owns 1% directly since Apr 30, 2007; Whmc Inc. owns 1% directly since Aug 26, 2011.
- 5 owners or officers are people: Eric D Smith (managing employee (under contract)); Demetrios P Magoulas (corporate officer); Demetrios P Magoulas (managing employee (on the payroll)); Kathryn Marietta (corporate officer); Kathryn Marietta (managing employee (on the payroll)).
- CMS’s Provider of Services file records 6 changes of ownership.
- 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% | Apr 30, 2007 |
| HCA Healthcare Inc. | Owns 5% or more through other companies | 100% | Sep 7, 2011 |
| Houston Healthcare Holdings, Inc. | Owns 5% or more through other companies | 100% | Apr 30, 2007 |
| Columbia/HCA of Houston, Inc. | Owns 5% or more through other companies | 100% | Apr 30, 2007 |
| Healthtrust Inc. - the Hospital Company | Owns 5% or more through other companies | 100% | Apr 30, 2007 |
| West Houston LLC | Owns 5% or more through other companies | 99% | Apr 30, 2007 |
| Whmc Inc. | Owns 5% or more through other companies | 99% | Apr 30, 2007 |
| Hti Hospital Holdings Inc. | Owns 5% or more through other companies | 24.76% | Apr 30, 2007 |
| Women’s Hospital Indianapolis, L.P. | Owns 5% or more through other companies | 18.27% | Apr 30, 2007 |
| 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% | Nov 17, 2006 |
| 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% | Apr 30, 2007 |
| Columbia Hospital Corporation - Delaware | Owns 5% or more through other companies | 6.49% | Apr 30, 2007 |
| Columbia Hospital Corporation of West Houston | Owns 5% or more through other companies | 5.61% | Apr 30, 2007 |
| 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% | Apr 30, 2007 |
| West Houston LLC | Owns 5% or more directly | 1% | Apr 30, 2007 |
| West Houston LLC | Limited partner | 1% | Aug 26, 2011 |
| Whmc Inc. | Owns 5% or more directly | 1% | Aug 26, 2011 |
| Whmc Inc. | General partner | Aug 26, 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 1 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.