Texas Health Huguley Hospital Fort Worth South
An acute care hospital in Fort Worth, Texas 76115
11801 South Freeway, Fort Worth, Texas 76115. (817) 293-9110.
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The short answer
Record last released by CMS on Oct 20, 2026.
- 3of 5 CMS’s overall rating
- 3of 5 patient survey rating
- 2 deficiencies cited in the last three years (needs attention)
- 386 beds
Each figure’s source sits beside it, in its section below.
What these words mean4
- 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.
- Condition-level deficiency
- 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.
What did inspectors find?
The last inspection on record was on Jul 21, 2026: a complaint inspection.
2 deficiencies cited in the last three years, 1 of them at condition level, the most serious.
1 deficiency at condition level, the more serious of CMS’s two levels
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
2 deficiencies in 1 month of the last 36. Last cited Jun 2026. Most serious: Condition-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.
Jun 10, 2026: complaint inspection2 deficiencies
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Surgical Services
The inspectors’ words, 197 words
“SURGICAL SERVICES CFR(s): 482.51 If the hospital provides surgical services, the services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. This Condition is not met as evidenced by: 46427 It was determined the Conditions of Participation for Surgical Services was not met as evidenced by. Based on record review and interview, Hospital A failed to ensure that its surgical services were well organized and provided in accordance with acceptable standards of practice. It failed to develop, approve, implement, and enforce policies that guided appropriate handling, storage and environment control of sterilized instruments in accordance with standard professional perioperative guidelines to minimize the potential for interrupted sterility through exposure to heat and excessive humidity, moisture, and condensation formation when staff failed to monitor and document temperature and humidity conditions of the transporting vehicle with sterile instruments between April 2026 and June 2026. This failure potentially increased the risk of contamination of sterile instruments for the 870 surgical cases performed at Hospital A during a two-month period. Cross Refer 0951”
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Operating Room Policies
The inspectors’ words, 855 words
“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 46427 Based on record review and interviews, the facility failed to design, implement, and enforce policies and procedures governing the off-site transport of sterile instruments to ensure appropriate handling, storage, and environmental controls during transit. Specifically, the facility failed to design policies to assure protection during transport to minimize the potential for damage, maintain sterility, monitor and document temperature and humidity conditions during the transport of sterilized instruments from Hospital B to Hospital A. This failure potentially increased the risk of contamination of sterile instruments by moisture, excessive humidity, and condensation caused by exposure to temperature extremes for the 870 surgical cases performed at Hospital A during a two-month period. Findings: During an interview with Personnel #3 on 05/26/2026 at 2:15 PM, Personnel #3 confirmed that Hospital A’s sterilizers had not been in use since 04/13/2026 due to physical environment reason at Hospital A and that instruments were transported to Hospital B for sterile processing per cargo van and subsequently transported from Hospital B back to Hospital A following sterilization. Personnel #3 also confirmed that temperature and humidity conditions were not monitored during the transport phase. During an interview with Personnel #4 on 05/26/2026 at 2:45 PM, Personnel #4 confirmed that Hospital A’s two surgical instrument sterilizers became inoperable on 04/13/2026. The hospital started transporting decontaminated instruments to Hospital B for sterilization on 04/13/2026. Personnel #4 was asked if the temperature and humidity levels were tracked and monitored during the transport phase. Personnel #4 confirmed the hospital initially had an infrared reader that checked the temperature of the van but did not check for humidity. Personnel #4 confirmed the facility followed the Association for the Advancement of Medical Instrumentation (AAMI) and the Association of Perioperative Registered Nurses (AORN) standards regarding offsite transportation of sterilized instruments. On 05/26/2026 at 2:45 PM the surveyor requested a review of the hospital approved policy and procedure that governed the offsite transport of sterile surgical instruments. None was provided. On 05/26/2026 at 2:30 PM the surveyor requested evidence that temperature and humidity controls were monitored and maintained during the transport of sterile instruments between Hospital B and Hospital A between 04/13/2026 and 05/26/2026. None was provided. Record review of a surgical case log dated 4/13/2026 to 06/03/2026 reflected approximately 870 surgical cases were performed at Hospital A. According to the National Weather Service for Dallas-Fort Worth area, May 2026, experienced nine days with thunderstorms, two days with heavy rain and sixteen days with light rain. The Dallas-Fort Worth climate summary also reported an average relative humidity of 65%. These weather conditions may have effected environmental conditions during the transport of sterile instruments. National Weather Service Association of Perioperative Registered Nursing (AORN) , Guidelines for Perioperative practice: Sterilization ...3.3 Establish and implement standardized sterile processing procedures and measures for oversight of all aspects of processing and transport, including when all instruments are processed at one facility, requiring transport of packaged sterilized items between facilities. 3.3.1 Transport vehicles used for off-site transportation should “ Have a cargo area that o has surfaces made of durable materials that can withstand cleaning and disinfection; o has controlled environmental conditions (e.g., temperature, humidity); o allows for complete separation of clean and sterile items from contaminated items (e.g., physical separation, use of a transport carrier ); o secures sterile packages and minimizes movement (e.g., shock, vibration) of sterile items to prevent damage and maintain integrity of the sterile barrier system; o allow for ease of loading and unloading; and o be attended in unsecured areas. ANSI/AAMI ST79:2017/(R)2022, & 2020 Amendments A1, A2, A3, A4 ...11.3 Transport of sterile packaged items ... 11.3.1 General considerations ...Written policies and procedures should be developed for the use of transport equipment, appropriate handling practices, and acceptable environmental conditions for the transport of sterile packages. Sterile items should be transported in a manner that will protect the items from puncture and from contamination by moisture, excessive humidity, condensation caused by exposure to temperature extremes, insects, vermin, dust and dirt, excessive air pressures, and microorganisms. Rationale: Adequate protection during transport minimizes the potential for damage and helps maintain sterility. 11.3.5 Off-site transportation ...Vehicles used to transport sterile packages between health care facilities should a) provide for the complete separation of clean and sterile items from contaminated items; b) have a storage compartment that is completely enclosed; and c) allow for ease of loading and unloading ... When vehicles are used, environmental conditions should be assessed while the vehicle is in motion and when it is not in motion. In geographical areas where high humidity is the norm, testing should be performed to determine the potential for absorbent items to become contaminated and for the contents of sterile packages to become wet from the condensate that can occur on metal or plastic surfaces. Vehicles that are loaded and ready for transport should not be left unattended in unsecured areas.”
All 6 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Jul 21, 2026 | Complaint inspection | No deficiencies cited |
| Jun 10, 2026 | Complaint inspection | 2 deficiencies cited |
| Oct 1, 2025 | Complaint inspection | No deficiencies cited |
| Jul 30, 2025 | Complaint inspection | No deficiencies cited |
| Jun 3, 2025 | Complaint inspection | No deficiencies cited |
| May 13, 2025 | 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, 1 better and 0 worse of 7; safety of care, 1 better and 0 worse of 6; readmission, 0 better and 1 worse of 7.
- Patients rate it 3 of 5 in CMS’s patient survey (1,449 surveys completed, Oct 1, 2024 to Sep 30, 2025): 74% rated it 9 or 10 out of 10, and 73% 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), no different than national benchmark; surgical site infections after colon surgery, no different than national benchmark; MRSA bloodstream infections, better than the 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 11.9%, heart failure 9.7%, pneumonia 12.3%, COPD 7.3%, stroke 11.4%. 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 13.5%, heart failure 20.2%, pneumonia 16.7%, COPD 19.7%, heart bypass surgery 12.3%, hip or knee replacement 5.4%. 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 188 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 2% left before being seen.
- 76% 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 1.05 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 | 3 of 5 |
Is it certified, and in good standing?
- Medicare-certified acute care hospital since Feb 28, 1977.
- Ownership: voluntary non-profit - private.
- It is accredited by The Joint Commission, whose surveys stand in for the state’s routine inspections.
- Cited at 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. in the last three years: it didn’t meet a whole condition of Medicare’s rules for hospitals.
- Voluntary non-profit - Private.
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.
- 2 deficiencies cited in the last three years came from inspections 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 3 of 5.
- 76% 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?
- Texas Health Resources owns 51% directly since May 1, 2012; Adventist Health System Sunbelt Inc. owns 49% directly since May 1, 2012.
- 26 owners or officers are people: Karsten Randolph (corporate officer, 0%); Karsten Randolph (corporate director, 0%); John Page (corporate director, 0%); Joshua Floren (corporate officer, 0%); Joshua Floren (corporate director, 0%); Andrew D Jahn (corporate officer, 0%); Andrew D Jahn (corporate director, 0%); Marisa Farabaugh (corporate officer, 0%); Michael Saunders (corporate officer, 0%); Rick E Mcwhorter (corporate officer, 0%); Audrey E. Gregory (corporate officer, 0%); Audrey E. Gregory (corporate director, 0%); Penny L Johnson (managing employee (under contract), 0%); Penny L Johnson (corporate director, 0%); Penny L Johnson (runs it (operational or managerial control), 0%); Michael Skinner (managing employee (on the payroll), 0%); Haney Vincent (corporate officer, 0%); Douglas Pytlinski (corporate officer, 0%); Todd A Goodman (corporate officer, 0%); Erin Parde (managing employee (under contract), 0%); Erin Parde (corporate officer, 0%); Erin Parde (runs it (operational or managerial control), 0%); Lynn Addiscott (corporate officer, 0%); Winjie T Miao (corporate director, 0%); Beverly Morgan (corporate officer, 0%); Trevor G Wright (corporate officer, 0%).
- CMS’s Provider of Services file records 1 change of ownership, the latest on May 1, 2012.
- 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 |
|---|---|---|---|
| Texas Health Resources | Owns 5% or more directly | 51% | May 1, 2012 |
| Adventist Health System Sunbelt Healthcare Corporation | Owns 5% or more through other companies | 49% | May 1, 2012 |
| Adventist Health System Sunbelt Inc. | Owns 5% or more directly | 49% | May 1, 2012 |
How does it compare nearby?
- Of the 30 hospitals CMS lists in Tarrant County, 17 have an overall star rating from CMS: 3 rated 5 of 5, 9 rated 4 of 5, 2 rated 3 of 5, 3 rated 2 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.