Hearth Record

St Luke’s Hospital at the Vintage

An acute care hospital in Houston, Texas 77070

20171 Chasewood Park Drive, Houston, Texas 77070. (832) 534-5000.

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 2 deficiencies in 1 month of the last 36. Last cited Oct 2024. Most serious: Condition-level. Every month

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 Feb 9, 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

Source:

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 Oct 2024. Most serious: Condition-level. The last 3 years, to Nov 5, 2026.

2 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.

Oct 3, 2024: complaint inspection2 deficiencies

  • Emergency Services

    The inspectors’ words, 103 words

    “EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 46010 Based on interviews and record review, the facility failed to ensure coordination of a safe discharge plan for Patient ID #2, who was a cognitively impaired group home patient, intended to return to a residential group home facility at discharge from the ED, but was allowed to leave unaccompanied, in an ambulatory fashion, from the ED lobby. This failed practice could result in serious harm or death to a patient. Refer to tag 1104.”

    Rule A1100. Condition-level. From a complaint.

  • Emergency Services Policies

    The inspectors’ words, 760 words

    “EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 46010 Based on medical record reviews, document reviews, and interviews, the facility failed to ensure a safe discharge for 1 of 24 patients reviewed (Patient #2). The facility failed to have a comprehensive Emergency Department (ED) policy and procedure, which included visual identification and/or communication of patients who arrived from group home and post-acute settings. The facility failed to ensure coordination of a safe discharge plan for Patient ID #2 who was a cognitively impaired group home patient, who was intended to be returning to residential group home facility, but allowed to leave unaccompanied, in an ambulatory fashion, from the ED lobby. Findings included: Telephone interview on 9/24/2024 at 09:35 am with Group Home Manager Staff ID #100. She stated that Patient ID #2 was a 70 year old genleman who had limited cognitive aptitude and psychiatric impairment, who required assistance to meet all activities of daily living, largely due to his cognitive and psychiatric impairments. She confirmed that Patient ID #2 had been brought to Facility’s ED department via EMS for syncopal episode on 08/20/2024. She stated the facility never contacted the facility and that no transportation arrangements had been made to ensure his safe return to his residential group home. She stated there had been no contact with facility staff regarding his ED visit, care provided and discharge/follow-up plans. Medical Record Review of Patient ID #2 with ED Nurse Manager Staff ID #55 on 10/1/2024 at 10:45 AM showed patient ID#2 arrived in the ED 8/20/2024 at 14:44 via ambulance for “syncopal episode.” The medical record reflected the patient had altered mental status. Patient left ambulatory from the ED unaccompanied with a disposition of Discharge 8/20/2024 at 7:53 PM. There was no evidence of communication with the group home or any responsible party at discharge. Medical Record Review of Patient ID#2 with ED Nurse Manager Staff ID #55 on 10/1/2024 at 10:45 AM showed patient ID#2 returned to the ED on 8/21/2024 via ambulance at 19:00 with chief complaint of “never was picked up by group home.” The record stated “patient here for heat exposure and dehydration. Patient was seen here yesterday for syncopal episode, left the hospital and spent the day in the parking lot with limited amount of water. Patient denies fever, chest pain, vomiting, diarrhea.” Patient ID #2 was admitted to the hospital from the ED on 8/22/2024 with acute kidney injury, rhabdomyolysis and dehydration. Record revealed he was ultimately discharged to the group home facility on 8/24/2024. Policy Review of Facility Policy titled “Care Coordination Discharge Planning”, effective 11/2022, stated “Roles & Responsibilities. Nursing - The bedside nurse is responsible for completing the discharge planning screening of all patients upon admission, ensuring that all necessary patient or caregiver/representative teaching has occurred, completing dishcarge instructions, providing written discharge instructions (including post-acute follow up) and reconciled medication list, and documenting discharge in the medical record. The bedside nurse will collaborate with other members of the multidisciplinary team as needed to ensure patient discharges. The discharging nurse will notify the patient’s designated caregiver/representative of the patient’s discharge or transfer to another facility as soon as possible, but at a minimum upon issuance of a discharge order by an attending physician. The discharging nurse will provide handoff communication to receiving facilities.” The policy stated “4. Documentation. All activities related to discharge planning, patient choice, and referrals are documented in the medical record including screenings, assessments/reassessments, evaluations, and arrangements made for implementation of the discharge plan....” Interview with ED Nurse Manager Staff ID #55 on 10/1/2024 at 11:15 AM confirmed that Patient ID #2 arrived via EMS from a group home, where he resided after a syncopal episode. Staff ID #55 confirmed there was no documentation or evidence that any coordination of care or communication occurred between group home and facility ED staff when the decision to discharge disposition occurred on 8/20/2024. He confirmed that the ED nursing staff are responsible for this coordination and communication for ED patients. He confirmed there was no electornic medical record identifier of patients who arrived from group home or post-acute settings. He confirmed there was not a specific policy and procedure for ED nurses for ensuring coordination of care and communication for group home patients as a component of a safe discharge plan.”

    Rule A1104. Standard-level. From a complaint.

All 5 inspections in the last three years
Inspections on record
DateVisitWhat the record says
Feb 9, 2026Complaint inspectionNo deficiencies cited
Oct 3, 2024Complaint inspection2 deficiencies cited
Aug 12, 2024Complaint inspectionNo deficiencies cited
Aug 8, 2024Complaint inspectionNo deficiencies cited
Feb 13, 2024Complaint 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, 0 better and 0 worse of 6; safety of care, 1 better and 0 worse of 5; readmission, 0 better and 0 worse of 6.
  • Patients rate it 3 of 5 in CMS’s patient survey (432 surveys completed, Oct 1, 2024 to Sep 30, 2025): 79% rated it 9 or 10 out of 10, and 81% 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), no different than 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 11.9%, heart failure 10.4%, pneumonia 13.5%, COPD 8.8%, stroke 9.6%. 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 13.3%, heart failure 20.9%, pneumonia 16.3%, COPD 20.4%. 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 209 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 0% left before being seen.
  • 64% 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 1.09 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 Dec 14, 2010.
  • Ownership: voluntary non-profit - private.
  • It is accredited by The Joint Commission, whose surveys stand in for the state’s routine inspections.
  • Cited at in the last three years: it didn’t meet a whole condition of Medicare’s rules for hospitals.
  • 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.
  • 2 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 4 of 5.
  • 71% 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?

  • St Lukes Health Clinical Operations owns 100% directly since Jul 1, 2021.
  • 16 owners or officers are people: Doug Lawson (corporate director, 0%); Doug Lawson (managing employee (on the payroll), 0%); Doug Lawson (other role (CMS gives no detail), 0%); Michael Steines (corporate director, 0%); Gary Whitlock (corporate director, 0%); Robert Upchurch (corporate director); Frank Ashley (corporate director, 0%); Brooks Bass (corporate director, 0%); Brad Beers (corporate director, 0%); Mario J Garner (corporate officer, 0%); Mario J Garner (runs it (operational or managerial control), 0%); Jane Ainsworth (corporate director, 0%); Indira S Anupindi (corporate director, 0%); David C. Strickler (corporate officer); David C. Strickler (runs it (operational or managerial control), 0%); Demetress L Harrell (corporate director, 0%).
  • CMS’s Provider of Services file records 1 change of ownership, the latest on Jan 1, 2014.
  • 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
St. Lukes Health System CorporationOwns 5% or more through other companies100%Jul 1, 2021
Commonspirit HealthOwns 5% or more through other companies100%Jan 1, 2014
St Lukes Health Clinical OperationsOwns 5% or more directly100%Jul 1, 2021

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
Houston Methodist Willowbrook Hospital5
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
Memorial Hermann Memorial City Hospital4
HCA Houston Healthcare Clear Lake4
HCA Houston Healthcare Northwest2

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.

1 of 4

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