P&P, Paid & Penalized

Public Medicare data, made visible.

HospitalSt Luke's the Woodlands Hospital Estimated FY2026 net: −$492K×

Hospital record · FY2026CCN 450862

1Hospital

St Luke's the Woodlands Hospital

2Location

The Woodlands, TX (Texas’s hospitals on the map and in the table) 77384

Montgomery County

3Type

Not a teaching hospital · 241 beds · Nonprofit · Urban

4Care Compare stars

3 of 5 stars

Overall rating, CMS Care Compare data of July 22, 2026
Open on Care Compare (opens in a new tab)

5Total HAC Score

1.2996

As CMS reports it

6Payment reduction

1% cut
CMS’s value: Yes

7Estimated cut

$339K estimate
Likely $259⁠–⁠427K; about $164 per traditional Medicare stay

Cut 1%

$339K

cut from its FY2026 Medicare inpatient payments, this site estimates estimate

For fiscal year 2026, CMS reports a Total HAC Score of 1.2996 for St Luke's the Woodlands Hospital and a payment reduction decision of Yes.

That is 1% of about $33.9M, this site’s estimate of what traditional Medicare pays it for inpatient stays in a year: about $164 per traditional Medicare stay.

Likely range $259–427K

Its score was above CMS’s line, so CMS cut its Medicare inpatient payments by 1% for the year. The score compares hospitals with each other; it is not a grade of the quality of care.

CMS cut scores of 0.3799 and above.

Each year CMS cuts the hospitals with the highest quarter of scores, those above the 75th percentile, so the line moves with other hospitals’ scores.

lowest −1.4728 1% cut Middle hospital: −0.0453 Middle hospital−0.0453 CMS’s line: 0.3799 and up CMS’s line0.3799 and up This hospital: 1.2996 This hospital 1.2996 lowest −1.4728 highest 2.3133 1% cut Middle hospital: −0.0453 Middle hospital−0.0453 CMS’s line: 0.3799 and up CMS’s line0.3799 and up This hospital: 1.2996 This hospital 1.2996

Higher than 97% of the other 2,928 scores CMS published (higher is worse).

Its record, fiscal years 2015 to 2026 Cut in 3 of 11 years

  1. 15No
  2. 16No
  3. 17Cut
  4. 18Cut
  5. 19No
  6. 20No
  7. 21No
  8. 22No
  9. 23—
  10. 24No
  11. 25No
  12. 26Cut

Where the score came from

CMS scored this hospital on all 6 measures. On every measure a lower value is better. Each row puts the hospital among every hospital with a value: the gray columns are those hospitals, the tall tick is the national median, and the hatched ends score the same as CMS’s floor or cap.

Bringing CLABSI down to the national median (0.559) would lower the score the most: by 0.2362, to 1.0634. Try it in the what-if

Figure 1. Of its 3 measures with a value, this hospital is above the national median on 3; CLABSI added the most to its score.
  • This hospital
  • National median
  • Scores the same as CMS’s floor or cap
  1. PSI 90 (what it counts)

    Safety problems such as serious bedsores, falls that break a bone and blood clots after surgery, found by CMS in traditional Medicare claims. A value of 1 matches the national composite value.

    Patient safety and adverse events composite

    Worse than 50% of the other 2,808 hospitals

    estimate

    This site recomputes this measure’s z‑score from CMS’s published value. The recompute can differ from CMS’s z‑score by up to 0.0021. How this site estimates

    CMS value0.9631

    Z-score−0.1768

    Part of score−0.0295

  2. CLABSI (what it counts)

    Bloodstream infections tied to a central line, a tube often placed in a large vein in the neck, chest or groin. Hospitals report them to the CDC’s National Healthcare Safety Network. A value of 1.0 means as many infections as the CDC’s model predicted.

    added the most

    Central line–associated bloodstream infections

    Worse than 88% of the other 2,181 hospitals

    CMS value1.170

    Z-score1.3077

    Part of score+0.2180

  3. CAUTI (what it counts)

    Urinary tract infections that start from a urinary catheter, a tube that drains the bladder. Hospitals report them to the CDC’s National Healthcare Safety Network. A value of 1.0 means as many infections as the CDC’s model predicted.

    Catheter-associated urinary tract infections

    Worse than 58% of the other 2,354 hospitals

    CMS value0.579

    Z-score0.0771

    Part of score+0.0129

  4. SSI (what it counts)

    Deep infections at the site of colon surgery or an abdominal hysterectomy, within a month of the operation, pooled into one measure. Hospitals report them to the CDC’s National Healthcare Safety Network. A value of 1.0 means as many infections as the CDC’s model predicted.

    Surgical site infections after colon surgery or abdominal hysterectomy

    CMS assigned this measure its worst possible score under the program’s rules; it is not a measured result. CMS’s footnote gives the reason.

    CMS footnote 11: There were discrepancies in the data collection process.

    CMS valueno value published

    Z-score2.1717

    Part of score+0.3620

  5. CDI (what it counts)

    C. diff infections, which cause diarrhea and inflammation of the colon, found by a lab test and starting in the hospital. Hospitals report them to the CDC’s National Healthcare Safety Network. A value of 1.0 means as many infections as the CDC’s model predicted.

    Clostridioides difficile (C. diff) infections

    CMS assigned this measure its worst possible score under the program’s rules; it is not a measured result. CMS’s footnote gives the reason.

    CMS footnote 11: There were discrepancies in the data collection process.

    CMS valueno value published

    Z-score2.1931

    Part of score+0.3655

  6. MRSA (what it counts)

    Bloodstream infections with MRSA, a germ that resists several antibiotics, found by a lab test and starting in the hospital. Hospitals report them to the CDC’s National Healthcare Safety Network. A value of 1.0 means as many infections as the CDC’s model predicted.

    MRSA bloodstream infections

    CMS assigned this measure its worst possible score under the program’s rules; it is not a measured result. CMS’s footnote gives the reason.

    CMS footnote 11: There were discrepancies in the data collection process.

    CMS valueno value published

    Z-score2.2251

    Part of score+0.3708

Source: CMS Provider Data Catalog, HACRP FY2026 (yq43-i98g), released August 13, 2026.

Show table
MeasureCMS valueNational medianZ-scorePart of the scoreAmong hospitals
PSI 900.96310.9623−0.1768−0.0295Worse than 50% of the other 2,808 hospitals
CLABSI1.1700.5591.3077+0.2180Worse than 88% of the other 2,181 hospitals
CAUTI0.5790.4890.0771+0.0129Worse than 58% of the other 2,354 hospitals
SSIno value published0.7952.1717+0.3620
CDIno value published0.3462.1931+0.3655
MRSAno value published0.6412.2251+0.3708

How the parts add up

CMS adds the z‑scores and divides by the number of measures scored, so each measure counts the same. Each bar below is one z‑score divided by 6; a bar right of zero raised the score and one left of zero lowered it.

(−0.1768PSI 90+1.3077CLABSI+0.0771CAUTI+2.1717SSI+2.1931CDI+2.2251MRSA)÷6measures=1.2996Total HAC Score

Added from the rounded z‑scores CMS published, the parts make 1.2997; CMS reports 1.2996. The small difference is rounding.

This hospital’s score is 0.9204 above 0.3792, the highest score CMS marked No. (This site recomputes.)

Figure 2. The parts add up to 1.2996, above CMS’s line.
1% cut PSI 90: z‑score −0.1768 divided by 6 = −0.0295PSI 90−0.0295 CLABSI: z‑score 1.3077 divided by 6 = +0.2180CLABSI+0.2180 CAUTI: z‑score 0.0771 divided by 6 = +0.0129CAUTI+0.0129 SSI: z‑score 2.1717 divided by 6 = +0.3620SSI+0.3620 CDI: z‑score 2.1931 divided by 6 = +0.3655CDI+0.3655 MRSA: z‑score 2.2251 divided by 6 = +0.3708MRSA+0.3708 Total HAC Score: 1.2996Score1.2996 CMS’s line: between 0.3792 and 0.3799 CMS’s line 0.00.51.0 1% cut PSI 90: z‑score −0.1768 divided by 6 = −0.0295PSI 90−0.0295 CLABSI: z‑score 1.3077 divided by 6 = +0.2180CLABSI+0.2180 CAUTI: z‑score 0.0771 divided by 6 = +0.0129CAUTI+0.0129 SSI: z‑score 2.1717 divided by 6 = +0.3620SSI+0.3620 CDI: z‑score 2.1931 divided by 6 = +0.3655CDI+0.3655 MRSA: z‑score 2.2251 divided by 6 = +0.3708MRSA+0.3708 Total HAC Score: 1.2996Score1.2996 CMS’s line: between 0.3792 and 0.3799 CMS’s line 0.00.51.0

This site recomputes · Source: CMS Provider Data Catalog, HACRP FY2026 (yq43-i98g), released August 13, 2026.

Show table
MeasureZ-scorePart of the scoreRunning total
PSI 90−0.1768−0.0295−0.0295
CLABSI1.3077+0.21800.1885
CAUTI0.0771+0.01290.2014
SSI2.1717+0.36200.5634
CDI2.1931+0.36550.9289
MRSA2.2251+0.37081.2997
Total HAC Score1.2996
CMS’s line0.37920.3799

The money is a cliff

This program’s cut doesn’t grow with the score. Over CMS’s line, CMS cuts 1% of what traditional Medicare pays a hospital for inpatient stays that year; at or under the line, this program cuts nothing.

The chart draws what the cut would be for this hospital at any Total HAC Score, from this site’s estimate of its payments, with its own score marked.

Figure 3. The cut is a cliff, not a slope: this hospital’s score, 0.9204 over the highest score CMS didn’t cut, costs it about $339K by this site’s estimate, and at CMS’s highest score, 2.3133, the cut would be the same.
CMS’s line $0 at any score up to 0.3792 $339K at any score from 0.3799 $0at any score up to 0.3792 $339K at any score from 0.3799 −1012 CMS’s highest score: 2.3133 This hospital: 1.2996 This hospital 1.2996 CMS’s line $0 at any score up to 0.3792 $339K at any score from 0.3799 $0at any score up to 0.3792 $339Kat any score from 0.3799 −1.0−0.50.00.51.01.52.0 CMS’s highest score: 2.3133 This hospital: 1.2996 This hospital 1.2996

Under the axis, every Total HAC Score CMS published: 306 of the 2,929 scored within 0.1 of CMS’s line, on one side or the other.

Estimate · Source: this site’s arithmetic on CMS’s FY2026 IPPS final rule files (the impact file, the rate tables and the value-based factors), its FY2026 HRRP supplemental file and HACRP FY2026 (yq43-i98g), released August 13, 2026.

Show table
ScoreTotal HAC ScoreEstimated HAC cut (whole dollars)
Any score up to 0.37920.3792$0
Any score from 0.37990.3799−$339,367
This hospital1.2996−$339,367
CMS’s highest score2.3133−$339,367

The money, line by line

This site estimates what traditional Medicare pays the hospital for a year of inpatient stays, from CMS’s FY2026 payment files, then applies Medicare’s three hospital quality programs: the readmissions and value-based adjustments to the base payment, and the HAC cut last, as the law sets.

The readmissions and value-based programs adjust only the base payment: the DRG rates times the hospital’s cases, and a Medicare-dependent hospital’s add-on. The HAC cut comes last and takes 1% of everything left, teaching, low-income-patient, outlier, capital and uncompensated care payments included.

($34,089,746payment−$87,768readmissions−$65,313value-based)×1%the cut=$339,367HAC cut

$339,367HAC cut÷2,070traditional Medicare stays=$164per traditional Medicare stay

Figure 4. This site estimates the HAC cut at $339K: 1% of the hospital’s whole inpatient payment, taken last. The readmissions and value-based adjustments, on the base alone, came to −$88K and −$65K.

Estimated Medicare inpatient payments · FY2026 estimate

What traditional Medicare pays it for inpatient stays
DRG payments at the federal rates the base $25,814,134
Many low-income patients (disproportionate share) $498,729
Outliers: unusually costly stays $493,308
Capital: buildings and equipment $2,123,493
Uncompensated care $5,160,082
Total, before the three programs $34,089,746
The three programs: two on the base, the HAC cut last
Readmissions (HRRP) base × (0.9966 − 1) −$87,768
Value-based purchasing (HVBP) base × (0.9975 − 1) −$65,313
After these two $33,936,665
HAC Reduction Program 1% of everything above; likely $259⁠–⁠427K −$339,367
Net of the three programs likely −$579K to −$397K −$492,448

Not paid to this hospital: a Medicare-dependent hospital add-on, teaching payments, a sole community hospital rate difference, and a low-volume adjustment.

Whole dollars, so every line adds up; the estimate is not that precise. Each likely range spans the middle 80% of the misses this site’s estimate made for similar hospitals (or for a wider group, where there were too few) when it was checked against their FY2024 cost reports: one year’s check, not a promise of how often a hospital’s actual figure lands inside.

Estimate · Source: this site’s arithmetic on CMS’s FY2026 IPPS final rule files (the impact file, the rate tables and the value-based factors), its FY2026 HRRP supplemental file and HACRP FY2026 (yq43-i98g), released August 13, 2026.

Show table
LineAmount (whole dollars)
DRG payments at the federal rates (the base)$25,814,134
Many low-income patients (disproportionate share)$498,729
Outliers: unusually costly stays$493,308
Capital: buildings and equipment$2,123,493
Uncompensated care$5,160,082
Total, before the three programs$34,089,746
Readmissions (HRRP) (base × (0.9966 − 1))−$87,768
Value-based purchasing (HVBP) (base × (0.9975 − 1))−$65,313
After these two$33,936,665
HAC Reduction Program (1% of everything above; likely $259–427K)−$339,367
Net of the three programs (likely −$579K to −$397K)−$492,448

What if a measure were different?

Change a measure’s value to see how this site recomputes the Total HAC Score, the payment reduction decision and, by its estimate, the money, starting from CMS’s values. The money doesn’t slide with the score: it drops off a cliff at CMS’s line.

The what-if needs JavaScript. Without it, the values below stay as they are.

Show table
CMS reportsHypothetical
Total HAC Score1.2996same
Payment reduction decisionYessame
Payment cut1%same
Estimated HAC cut estimate$339Ksame

CMS’s line: between 0.3792 and 0.3799

The faint ticks are CMS’s line in earlier years under the same formula, from about 0.300 (FY2022) to about 0.375 (FY2024). The line moves every year, so a hospital can cross it without changing anything.

CMS reports a Total HAC Score of 1.2996 and a payment reduction decision of Yes.

A what-if shows the formula’s arithmetic, not what a hospital could realistically change or how. CMS’s real result also depends on other hospitals.

What would it take?

Getting under CMS’s line would keep about $339K, this site estimates: the whole cut, however far under the score lands.

From CMS’s values, one measure at a time, with every other measure held at CMS’s value.

MeasureValue that would read NoNote
PSI 90not possible with this measure alone
CLABSInot possible with this measure alone
CAUTInot possible with this measure alone
SSICMS assigned this measure’s score, so there is no submitted value to solve for.
CDICMS assigned this measure’s score, so there is no submitted value to solve for.
MRSACMS assigned this measure’s score, so there is no submitted value to solve for.

Each measure weighs 1 ÷ 6 of the score.

Measure values

SIR 1.0 = as many infections as predicted · Lower is better

On each track the tick is the national median; shaded values score the same as the floor or cap, as this site fits them to CMS’s values.

CMS 0.9631 · median 0.9623 · floor 0.7760 · cap 1.3482 · each 0.1 = 0.1164

CMS 1.170 · median 0.559 · cap 1.572 · each 0.1 = 0.0387

CMS 0.579 · median 0.489 · cap 1.537 · each 0.1 = 0.0402

median 0.795 · cap 2.118 · each 0.1 = 0.0286

CMS assigned this measure’s score; CMS’s footnote in the table above gives the reason. Enter a value to see the score had it been submitted.

median 0.346 · cap 0.944 · each 0.1 = 0.0645

CMS assigned this measure’s score; CMS’s footnote in the table above gives the reason. Enter a value to see the score had it been submitted.

median 0.641 · cap 1.762 · each 0.1 = 0.0348

CMS assigned this measure’s score; CMS’s footnote in the table above gives the reason. Enter a value to see the score had it been submitted.

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Figure 5. CLABSI added the most to this hospital’s Total HAC Score of 1.2996 among its measured results: +0.2180.
  • PSI 90 −0.0295
  • CLABSI +0.2180
  • CAUTI +0.0129
  • SSI (assigned by CMS) +0.3620
  • CDI (assigned by CMS) +0.3655
  • MRSA (assigned by CMS) +0.3708

A measure adds its z‑score divided by 6, the number of measures scored. Bars right of the center line raise the score. Hatched: assigned by CMS.

This site recomputes · Source: CMS Provider Data Catalog, HACRP FY2026 (yq43-i98g), released August 13, 2026.

Show table
MeasureZ-scorePart of the scoreHypothetical
PSI 90−0.1768−0.0295same
CLABSI1.3077+0.2180same
CAUTI0.0771+0.0129same
SSI, assigned2.1717+0.3620same
CDI, assigned2.1931+0.3655same
MRSA, assigned2.2251+0.3708same

Interactive what-if at https://paidandpenalized.org/hacrp/hospital/450862/

Among hospitals with a Yes or No payment decision, CMS cut those with a published Total HAC Score of 0.3799 or higher and none at 0.3792 or lower. Maryland’s hospitals are scored but not subject to the reduction.

Held fixed: every other hospital’s results, CMS’s line, and each measure’s mean, spread, floor and cap as this site fits them to CMS’s published values.

Year by year

Where this hospital’s score fell among every hospital’s, each year CMS published one. A score near the top is among the highest; the shaded band is where CMS cut. Places compare across years even where CMS changed how it builds the score.

Its longest run: cut 2 years in a row.

Figure 6. CMS cut this hospital in 3 of the 11 years it made a decision.
highest middle lowest z‑scoresequal weights no scores FY2015: score 4.9250, higher than 38% of scores; not cutFY2016: score 4.7500, higher than 33% of scores; not cutFY2017: score 7.3000, higher than 87% of scores; cutFY2018: score 0.6082, higher than 85% of scores; cutFY2019: score 0.3059, higher than 72% of scores; not cutFY2020: score 0.0496, higher than 56% of scores; not cutFY2021: score −0.6077, higher than 15% of scores; not cutFY2022: score −0.8819, higher than 6% of scores; not cutFY2024: score 0.0752, higher than 58% of scores; not cutFY2025: score −0.0009, higher than 51% of scores; not cutFY2026: score 1.2996, higher than 97% of scores; cut 161820222426 highest middle lowest z‑scoresequal weights no scores FY2015: score 4.9250, higher than 38% of scores; not cutFY2016: score 4.7500, higher than 33% of scores; not cutFY2017: score 7.3000, higher than 87% of scores; cutFY2018: score 0.6082, higher than 85% of scores; cutFY2019: score 0.3059, higher than 72% of scores; not cutFY2020: score 0.0496, higher than 56% of scores; not cutFY2021: score −0.6077, higher than 15% of scores; not cutFY2022: score −0.8819, higher than 6% of scores; not cutFY2024: score 0.0752, higher than 58% of scores; not cutFY2025: score −0.0009, higher than 51% of scores; not cutFY2026: score 1.2996, higher than 97% of scores; cut 151617181920212223242526

● Red: a year CMS cut it ○ Hollow: a year it didn’t

This site recomputes · Source: CMS, HACRP hospital files for fiscal years 2015 to 2026 (Provider Data Catalog, its archives and, for the oldest years, the Internet Archive’s copies), and CMS’s cut lists for FY2015 and FY2016.

Show table
Fiscal yearTotal HAC ScoreHigher than this share of scoresPayment reduction
FY20154.925038.8%not cut
FY20164.750033.4%not cut
FY20177.300087.1%cut
FY20180.608285.8%cut
FY20190.305972.8%not cut
FY20200.049656.4%not cut
FY2021−0.607715.2%not cut
FY2022−0.88196.7%not cut
FY2023no decision
FY20240.075258.6%not cut
FY2025−0.000951.9%not cut
FY20261.299697.3%cut

Its infections, year by year

This hospital’s infection rate against prediction for each calendar year Care Compare published one, on each measure with at least two years of results (black), over the nation’s middle hospital (gray). Below the dashed line at one, fewer infections than predicted. Each year is measured against the same fixed baseline, not against other hospitals, so unlike the score they can all improve at once.

Figure 7. 3 of its 6 infection measures ended lower than they started.
CLABSI 0.88 → 1.09 1as predicted 0 ’18’21’24 Nation’s middle CLABSI, 2017: 0.884CLABSI, 2018: 0.499CLABSI, 2019: 0.332CLABSI, 2021: 0.379CLABSI, 2022: 0.635CLABSI, 2023: 1.261CLABSI, 2024: 1.091 CAUTI 1.17 → 0.75 1 0 ’18’21’24 CAUTI, 2017: 1.174CAUTI, 2018: 0.656CAUTI, 2019: 0.332CAUTI, 2021: 0.585CAUTI, 2022: 0.606CAUTI, 2023: 0.398CAUTI, 2024: 0.750 SSI, colon 1.10 → 1.04 1 0 ’18’21’24 SSI, colon, 2017: 1.101SSI, colon, 2018: 0.000SSI, colon, 2019: 0.461SSI, colon, 2021: 0.363SSI, colon, 2022: 0.311SSI, colon, 2023: 0.511SSI, colon, 2024: 1.041 SSI, hysterectomy 0.81 → 2.04 1 0 ’18’21’24 SSI, hysterectomy, 2018: 0.805SSI, hysterectomy, 2019: 0.000SSI, hysterectomy, 2021: 0.000SSI, hysterectomy, 2022: 0.585SSI, hysterectomy, 2023: 1.325SSI, hysterectomy, 2024: 2.040 MRSA 0.00 → 1.46 1 0 ’18’21’24 MRSA, 2017: 0.000MRSA, 2018: 0.878MRSA, 2019: 0.000MRSA, 2021: 2.106MRSA, 2022: 2.344MRSA, 2023: 1.453MRSA, 2024: 1.455 C. diff 1.29 → 0.11 1 0 ’18’21’24 C. diff, 2017: 1.291C. diff, 2018: 0.781C. diff, 2019: 0.369C. diff, 2021: 0.319C. diff, 2022: 0.423C. diff, 2023: 0.104C. diff, 2024: 0.111 CLABSI 0.88 → 1.09 1as predicted 0 ’18’20’22’24 Nation’s middle CLABSI, 2017: 0.884CLABSI, 2018: 0.499CLABSI, 2019: 0.332CLABSI, 2021: 0.379CLABSI, 2022: 0.635CLABSI, 2023: 1.261CLABSI, 2024: 1.091 CAUTI 1.17 → 0.75 1 0 ’18’20’22’24 CAUTI, 2017: 1.174CAUTI, 2018: 0.656CAUTI, 2019: 0.332CAUTI, 2021: 0.585CAUTI, 2022: 0.606CAUTI, 2023: 0.398CAUTI, 2024: 0.750 SSI, colon 1.10 → 1.04 1 0 ’18’20’22’24 SSI, colon, 2017: 1.101SSI, colon, 2018: 0.000SSI, colon, 2019: 0.461SSI, colon, 2021: 0.363SSI, colon, 2022: 0.311SSI, colon, 2023: 0.511SSI, colon, 2024: 1.041 SSI, hysterectomy 0.81 → 2.04 1 0 ’18’20’22’24 SSI, hysterectomy, 2018: 0.805SSI, hysterectomy, 2019: 0.000SSI, hysterectomy, 2021: 0.000SSI, hysterectomy, 2022: 0.585SSI, hysterectomy, 2023: 1.325SSI, hysterectomy, 2024: 2.040 MRSA 0.00 → 1.46 1 0 ’18’20’22’24 MRSA, 2017: 0.000MRSA, 2018: 0.878MRSA, 2019: 0.000MRSA, 2021: 2.106MRSA, 2022: 2.344MRSA, 2023: 1.453MRSA, 2024: 1.455 C. diff 1.29 → 0.11 1 0 ’18’20’22’24 C. diff, 2017: 1.291C. diff, 2018: 0.781C. diff, 2019: 0.369C. diff, 2021: 0.319C. diff, 2022: 0.423C. diff, 2023: 0.104C. diff, 2024: 0.111

Source: CMS Care Compare, healthcare-associated infections by hospital, calendar years 2017 to 2024 (Provider Data Catalog archives; the oldest year through the Internet Archive’s copy).

Show table
Calendar yearCLABSICAUTISSI, colonSSI, hysterectomyMRSAC. diff
20170.8841.1741.1010.0001.291
20180.4990.6560.0000.8050.8780.781
20190.3320.3320.4610.0000.0000.369
20210.3790.5850.3630.0002.1060.319
20220.6350.6060.3110.5852.3440.423
20231.2610.3980.5111.3251.4530.104
20241.0910.7501.0412.0401.4550.111

Among hospitals like it

Each row is a group this hospital belongs to, drawn from every hospital in it with a payment decision. Red columns are hospitals past CMS’s line, the ones CMS cut; the short tick is the group’s middle score.

In Texas, its score is higher than 96% of the other 254 scored there.

In Houston-Pasadena-The Woodlands, TX area, its score is higher than 95% of the other 44 scored there.

Figure 8. Its score is above the middle in all 8 groups it belongs to; the share cut runs from 13% (Texas) to 26% (Nonprofit).
All hospitals: CMS cut 718 of 2,886 (25%); middle score −0.0453All hospitals 2,886 hospitals25% cut South region: CMS cut 263 of 1,174 (22%); middle score −0.1056South region 1,174 hospitals22% cut Texas: CMS cut 32 of 255 (13%); middle score −0.2368Texas 255 hospitals13% cut Houston-Pasadena-The Woodlands, TX area: CMS cut 6 of 45 (13%); middle score −0.3709Houston-Pasadena-The Woodlands, TX area45 hospitals13% cut Not teaching: CMS cut 389 of 1,563 (25%); middle score −0.1053Not teaching 1,563 hospitals25% cut 100 to 299 beds: CMS cut 275 of 1,193 (23%); middle score −0.0732100 to 299 beds 1,193 hospitals23% cut Nonprofit: CMS cut 478 of 1,830 (26%); middle score −0.0134Nonprofit 1,830 hospitals26% cut Urban: CMS cut 510 of 2,241 (23%); middle score −0.0574Urban 2,241 hospitals23% cut CMS’s line: between 0.3792 and 0.3799 CMS’s line −1012 This hospital: 1.2996 This hospital 1.2996 All hospitals: CMS cut 718 of 2,886 (25%); middle score −0.0453All hospitals2,886 hospitals25% cut South region: CMS cut 263 of 1,174 (22%); middle score −0.1056South region1,174 hospitals22% cut Texas: CMS cut 32 of 255 (13%); middle score −0.2368Texas255 hospitals13% cut Houston-Pasadena-The Woodlands, TX area: CMS cut 6 of 45 (13%); middle score −0.3709Houston-Pasadena-The Woodlands, TX area45 hospitals13% cut Not teaching: CMS cut 389 of 1,563 (25%); middle score −0.1053Not teaching1,563 hospitals25% cut 100 to 299 beds: CMS cut 275 of 1,193 (23%); middle score −0.0732100 to 299 beds1,193 hospitals23% cut Nonprofit: CMS cut 478 of 1,830 (26%); middle score −0.0134Nonprofit1,830 hospitals26% cut Urban: CMS cut 510 of 2,241 (23%); middle score −0.0574Urban2,241 hospitals23% cut CMS’s line: between 0.3792 and 0.3799 CMS’s line −1.5−1.0−0.50.00.51.01.52.0 This hospital: 1.2996 This hospital 1.2996

Source: CMS Provider Data Catalog, HACRP FY2026 (yq43-i98g), released August 13, 2026.

Show table
GroupWith a decisionHospitals cutShare cutMiddle scoreHospital higher than
All hospitals2,88671825%−0.045397%
South region1,17426322%−0.105696%
Texas2553213%−0.236896%
Houston-Pasadena-The Woodlands, TX area45613%−0.370995%
Not teaching1,56338925%−0.105396%
100 to 299 beds1,19327523%−0.073298%
Nonprofit1,83047826%−0.013498%
Urban2,24151023%−0.057498%
This hospital1.2996
CMS’s line0.37920.3799

The nearest hospitals

The 8 closest hospitals with a Total HAC Score, in a straight line. The squares are each hospital’s measures in order: filled, above the national median; open, at or below it; hatched, assigned by CMS; blank, not scored.

Figure 9. CMS cut 1 of the 8 nearest hospitals; the closest is less than a mile away.
5 mi10 mi8. Memorial Hermann Surgical Hospital Kingwood, Kingwood: score −0.7848, not cut, 16 miles87. HCA Houston Healthcare Northwest, Houston: score −0.2277, not cut, 14 miles76. Tops Surgical Specialty Hospital, Houston: score −0.2970, not cut, 13 miles65. HCA Houston Healthcare Tomball, Tomball: score −0.8703, not cut, 13 miles54. HCA Houston Healthcare Conroe, Conroe: score 0.5000, cut, 6 miles43. The Woodlands Specialty Hospital, Spring: score 0.0143, not cut, 5 miles32. Houston Methodist the Woodlands Hospital, The Woodlands: score −0.8967, not cut, 2 miles21. CHI St Lukes Lakeside Hospital, The Woodlands: score −0.6604, not cut, less than a mile1This hospital: St Luke's the Woodlands Hospital

Source: CMS Provider Data Catalog, HACRP FY2026 (yq43-i98g), released August 13, 2026.

Show table
HospitalMilesScoreDecision
CHI St Lukes Lakeside Hospital, The Woodlands, TXunder 1−0.6604not cut
Houston Methodist the Woodlands Hospital, The Woodlands, TX2−0.8967not cut
The Woodlands Specialty Hospital, Spring, TX50.0143not cut
HCA Houston Healthcare Conroe, Conroe, TX60.5000cut
HCA Houston Healthcare Tomball, Tomball, TX13−0.8703not cut
Tops Surgical Specialty Hospital, Houston, TX13−0.2970not cut
HCA Houston Healthcare Northwest, Houston, TX14−0.2277not cut
Memorial Hermann Surgical Hospital Kingwood, Kingwood, TX16−0.7848not cut

#HospitalMilesScoreDecisionEst. cut ($, modeled)Measures
1CHI St Lukes Lakeside HospitalThe Woodlands, TXunder 1−0.6604No cut$0Above the national median on 0 of 1 measures
2Houston Methodist the Woodlands HospitalThe Woodlands, TX2−0.8967No cut$0Above the national median on 1 of 6 measures
3The Woodlands Specialty HospitalSpring, TX50.0143No cut$0Above the national median on 1 of 1 measures
4HCA Houston Healthcare ConroeConroe, TX60.50001% cut$413KAbove the national median on 4 of 6 measures
5HCA Houston Healthcare TomballTomball, TX13−0.8703No cut$0Above the national median on 1 of 6 measures
6Tops Surgical Specialty HospitalHouston, TX13−0.2970No cut$0Above the national median on 0 of 1 measures
7HCA Houston Healthcare NorthwestHouston, TX14−0.2277No cut$0Above the national median on 2 of 6 measures
8Memorial Hermann Surgical Hospital KingwoodKingwood, TX16−0.7848No cut$0Above the national median on 1 of 2 measures

Download all hospitals’ data (CSV) · Data dictionary · CMS’s dataset page

CMS’s footnotes on this page

11
There were discrepancies in the data collection process.

How the program works, and how to find another hospital

A penalty reflects how CMS’s formula scored relative performance; it is not a verdict on the quality of care.

Cite this page

Paid & Penalized. St Luke's the Woodlands Hospital, The Woodlands, TX: Hospital-Acquired Conditions, FY2026. https://paidandpenalized.org/hacrp/hospital/450862/. Source: CMS Provider Data Catalog, HACRP FY2026 (yq43-i98g), released August 13, 2026.