Cycle 1
Health 2025-10-07 · Fire 2025-10-07
13 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Houston, TX
Holly Hall
3-star overall rating with 3-star inspections with 13 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
2000 Holly Hall St, Houston, TX
(713) 799-9031
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
62
Certified beds
Average residents
36
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2012-02-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.54
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.38
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.61
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
4.53
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.92
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.84
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.38
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.53
CMS adjusted RN staffing hours
Adjusted total hours
4.44
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
70%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,977
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.39
Composite VBP score used to determine payment impact.
Payment multiplier
0.9883
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.02% · Performance 21.68% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
8.08
Baseline 6.98% · Performance 5.42% · Measure score 8.08 · Achievement 8.08 · Improvement 7.36
Total nurse turnover
0.62
Baseline 75.00% · Performance 69.39% · Measure score 0.62 · Achievement 0 · Improvement 0.62
Adjusted total nurse staffing
5.06
Baseline 5.13 hours · Performance 4.52 hours · Measure score 5.06 · Achievement 5.06 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.6% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 178 · Observed rate 11.8% · Lower 95% interval 8.58% |
| Discharge to community | 51.84% |
50.57%
1.3 pts better
|
No Different than the National Rate · Eligible stays 192 · Observed rate 40.63% · Lower 95% interval 43.65% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 94.87% |
95.27%
0.4 pts worse
|
Numerator 111 · Denominator 117 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 117 |
| Discharge self-care score | 32.2% |
53.69%
21.5 pts worse
|
Numerator 19 · Denominator 59 |
| Discharge mobility score | 35.59% |
50.94%
15.3 pts worse
|
Numerator 21 · Denominator 59 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 117 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.42% |
7.12%
1.7 pts better
|
No Different than the National Rate · Eligible stays 135 · Observed rate 5.19% · Lower 95% interval 3.42% |
| Staff COVID-19 vaccination coverage | 1.14% |
8.2%
7.1 pts worse
|
Numerator 1 · Denominator 88 |
| Staff flu vaccination coverage | 38.1% |
42%
3.9 pts worse
|
Numerator 16 · Denominator 42 |
| Discharge function score | 47.46% |
56.45%
9 pts worse
|
Numerator 28 · Denominator 59 |
| Transfer of health information to provider | 94.34% |
95.95%
1.6 pts worse
|
Numerator 50 · Denominator 53 |
| Transfer of health information to patient | 98.36% |
96.28%
2.1 pts better
|
Numerator 60 · Denominator 61 |
| Resident COVID-19 vaccinations up to date | 38.3% |
25.2%
13.1 pts better
|
Numerator 18 · Denominator 47 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 46.6% |
97.1%
50.5 pts worse
|
93.4%
46.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 46.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
3.3%
3.3 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.0% |
18.9%
12.9 pts better
|
19.6%
13.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.0% |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.9% |
16.1%
4.8 pts worse
|
14.9%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
0.8%
1 pts worse
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.3% |
15.0%
10.3 pts worse
|
19.8%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.3% |
| Percentage of long-stay residents with pressure ulcers | 10.9% |
4.2%
6.7 pts worse
|
5.1%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 38.0% |
89.7%
51.7 pts worse
|
81.7%
43.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 23.7% · Q3 50.0% · Q4 76.8% · 4Q avg 38.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.7% |
12.0%
4.3 pts better
|
12.0%
4.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.7% · Observed 7.7% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 40.4% |
88.0%
47.6 pts worse
|
79.7%
39.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 40.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.1% |
25.9%
3.2 pts worse
|
23.9%
5.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.1% · Observed 35.2% · Expected 28.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-29 · Fire 2024-08-29
4 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-06-08 · Fire 2023-06-08
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-10-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-01
F · Potential for more than minimal harm
2025-10-07
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-10-01
E · Potential for more than minimal harm
2024-08-29
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-07
F · Potential for more than minimal harm
2023-06-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-07-21
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-10-07
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-10-08
E · Potential for more than minimal harm
2025-10-07
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-10-08
E · Potential for more than minimal harm
2025-10-07
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-10-08
E · Potential for more than minimal harm
2025-10-07
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-10-08
E · Potential for more than minimal harm
2025-10-07
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-10-08
E · Potential for more than minimal harm
2025-10-07
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-10-08
E · Potential for more than minimal harm
2025-10-07
F779 · Administration Deficiencies
Health
Keep signed and dated reports of x-rays and other diagnostic services in the residents record.
Corrected 2025-10-08
D · Potential for more than minimal harm
2025-10-07
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2025-10-08
D · Potential for more than minimal harm
2025-10-07
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-10-08
D · Potential for more than minimal harm
2025-10-07
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-10-08
D · Potential for more than minimal harm
2025-10-07
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-10-08
D · Potential for more than minimal harm
2025-10-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-08
B · Minimal harm
2025-10-07
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-10-08
D · Potential for more than minimal harm
2024-10-03
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-11-05
D · Potential for more than minimal harm
2024-06-29
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-08-14
E · Potential for more than minimal harm
2024-04-03
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-04-24
E · Potential for more than minimal harm
2024-04-03
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-04-24
E · Potential for more than minimal harm
2023-06-08
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-07-28
E · Potential for more than minimal harm
2023-06-08
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-07-28
E · Potential for more than minimal harm
2023-06-08
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-07-28
E · Potential for more than minimal harm
2023-06-08
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-08
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-08
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-07-28
Penalties and ownership
What sits behind the stars
Ownership
Clouse, Autumn
Corporate Director · Individual
Drew, Peter
Operational/Managerial Control · Individual
Drew, Peter
Corporate Officer · Individual
Holly Hall
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Garden Terrace Healthcare Center Of Houston
Houston, TX
3-star overall rating with 2-star inspections with $154,564 in total fines with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
The Methodist Hospital SNF
Houston, TX
5-star overall rating with 5-star inspections
#3
Bayou Manor
Houston, TX
5-star overall rating with 5-star inspections with $57,184 in total fines with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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