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Holly Hall
2000 Holly Hall St, Houston, TX 77054 · CMS Certification Number (CCN) 676306
At a glance
- CMS overall rating
- ★★★☆☆ 3 of 5
- Health inspection citations
- 24 in the last 3 inspection cycles (0 immediate jeopardy, 0 actual harm, 4 from complaints)
- Fire safety citations
- 4
- Fines (last 3 years)
- 0 fines, total $0
- Payment denials
- 0
- Most recent standard inspection
- October 7, 2025
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | Texas average | U.S. average |
|---|---|---|---|
| Overall | ★★★☆☆ 3 of 5 | 2.7 | 3 |
| Health inspections | ★★★☆☆ 3 of 5 | 2.8 | 2.8 |
| Staffing | ★★★★☆ 4 of 5 | 1.9 | 2.9 |
| Quality measures | ★★★★☆ 4 of 5 | 3.7 | 3.6 |
| Long-stay quality | ★★★★☆ 4 of 5 | Not published | Not published |
| Short-stay quality | ★★★☆☆ 3 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | October 7, 2025 | 13 | 13 | 0 |
| Cycle 2 | August 29, 2024 | 4 | 0 | 4 |
CMS weighted health inspection score: 63 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
24 health citations across 5 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
October 7, 2025: 13 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/08/2025 |
| B | F-0814 | Dispose of garbage and refuse properly. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/08/2025 |
| D | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/08/2025 |
| E | F-0779 | Keep signed and dated reports of x-rays and other diagnostic services in the residents record. Administration Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/08/2025 |
| D | F-0770 | Provide timely, quality laboratory services/tests to meet the needs of residents. Administration Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/08/2025 |
| D | F-0761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/08/2025 |
| E | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/08/2025 |
| E | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/08/2025 |
| D | F-0693 | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/08/2025 |
| E | F-0692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/08/2025 |
| E | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/08/2025 |
| E | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/08/2025 |
| E | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/08/2025 |
October 3, 2024: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 11/05/2024 |
June 29, 2024: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0678 | Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 08/14/2024 |
April 3, 2024: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 04/24/2024 |
| E | F-0584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 04/24/2024 |
June 8, 2023: 7 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/28/2023 |
| E | F-0758 | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/28/2023 |
| D | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/28/2023 |
| D | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/28/2023 |
| E | F-0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/28/2023 |
| D | F-0640 | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/28/2023 |
| E | F-0552 | Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/28/2023 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Fire safety inspections
4 fire safety citations across 3 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 10/07/2025 | F | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 10/01/2025 |
| 10/07/2025 | F | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 10/01/2025 |
| 08/29/2024 | E | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 10/07/2024 |
| 06/08/2023 | F | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 07/21/2023 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Penalties
No fines or payment denials published for this facility in the CMS Penalties file (last 3 years).
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Staffing
| Measure | This facility | Texas average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 4.74 | 3.39 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.56 | 0.43 | 0.69 |
| LPN/LVN hours per resident per day | 1.45 | Not published | Not published |
| Nurse aide hours per resident per day | 2.73 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 4.15 | Not published | Not published |
| RN hours per resident per day, weekends | 0.43 | Not published | Not published |
| Total nursing staff turnover (%) | 58.7 | 55.3 | 45.8 |
| Registered nurse turnover (%) | 40 | Not published | Not published |
| Administrators who have left | 0 | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Facility details
- Legal business name
- Holly Hall
- Ownership type
- For profit - Limited Liability company
- Chain
- Not published
- Ownership changed in last 12 months
- No
- Certified beds
- 62
- Average residents per day
- 37.5
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- None
- First approved for Medicare/Medicaid
- February 2, 2012
- County/parish
- Harris
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Owners and managers reported to CMS
4 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| CLOUSE, AUTUMN | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| DREW, PETER | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| HOLLY HALL | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| DREW, PETER | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Check it yourself
- Medicare Care Compare: Holly Hall. Full inspection reports, quality measures and staffing.
- HHSC long-term care complaint portal (TULIP). The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 26, 2026. Not a ranking or endorsement.