Holly Hall
Open-data reference.
Holly Hall is a for profit - limited liability company facility in Houston, TX with 62 certified beds and a 3-star overall CMS rating. The facility has 24 deficiency records on file.
2000 Holly Hall St, Houston, TX 77054
Phone: 7137999031
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 676306
- Ownership
- For profit - Limited Liability company
- Provider Type
- Medicare and Medicaid
- Beds
- 62
- Residents
- 36
- In Hospital
- No
- County
- Harris
- Last Inspection
- Oct 7, 2025
Staffing Data
- RN Hours
- 0.54 (nat'l avg: 0.68)
- LPN Hours
- 1.38
- CNA Hours
- 2.61
- Total Nursing Hours
- 4.53 (nat'l avg: 3.89)
- PT Hours
- 0.13
- Nursing Turnover
- 55.3%
- RN Turnover
- 70.0%
What the CMS Record Reveals About Holly Hall
Holly Hall operates 62 certified beds in Houston, TX with approximately 36 residents currently in care, and carries a CMS overall rating of 3 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (3★), staffing levels (3★), and quality measures (4★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 24 deficiency records from recent surveys, all falling in the no-harm or minimal-harm bands of the CMS scope-and-severity grid. No fines or payment denials have been assessed against this provider, suggesting issues — if any — did not rise to the enforcement threshold. Staffing is reported at 4.53 total nursing hours per resident day (national average 3.89), with RN coverage at 0.54 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "For profit - Limited Liability company" ownership and operating as a "Medicare and Medicaid" provider, Holly Hall falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 55.3%, above the level where continuity of care typically begins to suffer. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (24 most recent)
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Oct 8, 2025
Dispose of garbage and refuse properly.
Category: Nutrition and Dietary Deficiencies
Corrected: Oct 8, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Oct 8, 2025
Keep signed and dated reports of x-rays and other diagnostic services in the residents record.
Category: Administration Deficiencies
Corrected: Oct 8, 2025
Provide timely, quality laboratory services/tests to meet the needs of residents.
Category: Administration Deficiencies
Corrected: Oct 8, 2025
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.
Category: Pharmacy Service Deficiencies
Corrected: Oct 8, 2025
Ensure that residents are free from significant medication errors.
Category: Pharmacy Service Deficiencies
Corrected: Oct 8, 2025
Ensure medication error rates are not 5 percent or greater.
Category: Pharmacy Service Deficiencies
Corrected: Oct 8, 2025
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.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 8, 2025
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 8, 2025
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 8, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 8, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Oct 8, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 5, 2024
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 14, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 24, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Apr 24, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Jul 28, 2023
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.
Category: Pharmacy Service Deficiencies
Corrected: Jul 28, 2023
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Jul 28, 2023
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 28, 2023
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 28, 2023
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 28, 2023
Ensure that residents are fully informed and understand their health status, care and treatments.
Category: Resident Rights Deficiencies
Corrected: Jul 28, 2023
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 20.9% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 0.0% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 1.8% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 0.0% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 46.6% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 38.0% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.0% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | N/A | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 6.0% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | N/A | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 40.4% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 10.9% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 25.3% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | N/A | Yes |
Penalty History
No penalties on record.
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Frequently Asked Questions
What is the overall CMS rating for Holly Hall?
What are the staffing levels at Holly Hall?
How many beds does Holly Hall have?
Does Holly Hall have any deficiencies on record?
Has Holly Hall received any fines or penalties?
Who owns Holly Hall?
When was Holly Hall last inspected?
What quality measures are tracked for Holly Hall?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.