01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-10-07 | 13 | 2025-10-07 | 2 |
| Cycle 2 | 2024-08-29 | 1 | 2024-08-29 | 1 |
| Cycle 3 | 2023-06-08 | 10 | 2023-06-08 | 1 |
CMS CCN 6763062026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Holly Hall
2000 Holly Hall St · Houston, TX 77054 · Harris County
Certified beds62CMS provider file
Recent citation rows28current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
28 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 2 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-10-07 · HEALTHF0550Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2025-10-082025-10-07 · HEALTHF0677Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2025-10-082025-10-07 · HEALTHF0690Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Correction field: Deficient, Provider has date of correction · 2025-10-082025-10-07 · HEALTHF0692Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Correction field: Deficient, Provider has date of correction · 2025-10-082025-10-07 · HEALTHF0693Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-10-082025-10-07 · HEALTHF0759Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Correction field: Deficient, Provider has date of correction · 2025-10-082025-10-07 · HEALTHF0760Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2025-10-082025-10-07 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-10-082025-10-07 · HEALTHF0770Severity D · isolated; potential for more than minimal harm
Administration Deficiencies
Provide timely, quality laboratory services/tests to meet the needs of residents.
Correction field: Deficient, Provider has date of correction · 2025-10-082025-10-07 · HEALTHF0779Severity E · pattern; potential for more than minimal harm
Administration Deficiencies
Keep signed and dated reports of x-rays and other diagnostic services in the residents record.
Correction field: Deficient, Provider has date of correction · 2025-10-082025-10-07 · HEALTHF0812Severity D · isolated; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-10-082025-10-07 · HEALTHF0814Severity B · pattern; potential for minimal harm
Nutrition and Dietary Deficiencies
Dispose of garbage and refuse properly.
Correction field: Deficient, Provider has date of correction · 2025-10-082025-10-07 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-10-082025-10-07 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-10-012025-10-07 · FIREK0355Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Correction field: Deficient, Provider has date of correction · 2025-10-012024-10-03 · HEALTHF0677Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2024-11-05 · complaint2024-08-29 · FIREK0324Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2024-10-072024-06-29 · HEALTHF0678Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Correction field: Deficient, Provider has date of correction · 2024-08-14 · complaint2024-04-03 · HEALTHF0584Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-04-24 · complaint2024-04-03 · HEALTHF0677Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2024-04-24 · complaint2023-06-08 · HEALTHF0552Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Correction field: Deficient, Provider has date of correction · 2023-07-282023-06-08 · HEALTHF0640Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Correction field: Deficient, Provider has date of correction · 2023-07-282023-06-08 · HEALTHF0655Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Correction field: Deficient, Provider has date of correction · 2023-07-282023-06-08 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2023-07-2803 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- CLOUSE, AUTUMNIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/15/2019
- DREW, PETERIndividual · CORPORATE OFFICERNOT APPLICABLE · since 08/01/2022
- HOLLY HALLOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/01/2018
- DREW, PETERIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 08/01/2022
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours4.74per resident day
RN hours0.56per resident day
Weekend nurse hours4.15per resident day
Staff turnover58.7%CMS reported field
06 / LOCAL RECORDS
Open the Houston ledger →Other published facilities nearby
Afton Oaks Nursing And Rehabilitation Center169 beds · CMS overall 1/544 citation rowsAshford Gardens202 beds · CMS overall 2/537 citation rowsAvir At Arden Wood174 beds · CMS overall 2/550 citation rowsAvir At Courtyard120 beds · CMS overall 4/526 citation rowsAvir At Golfcrest200 beds · CMS overall 2/532 citation rowsAvir At Houston148 beds · CMS overall 1/551 citation rowsAvir At Orem120 beds · CMS overall 4/537 citation rowsAvir At Veterans Memorial120 beds · CMS overall 1/538 citation rows