For profit - Limited Liability company · 62 certified beds · CMS number 676306
Holly Hall, Houston, TX
CMS records 24 health deficiencies at Holly Hall in Houston, Texas in its last 3 inspection cycles; the Texas median is 25. Its most recent standard inspection was on Oct 7, 2025. The highest severity cited is E (no actual harm, potential for more than minimal harm). CMS lists no fines or payment denials in the last three years.
- 24deficiencies, 3 cycles (TX median 25)
- 13in the latest cycle (TX median 8)
- Ehighest severity · Potential for harm
- $0fines, last 3 years
- 3CMS overall rating (of 5)
Inspections and deficiencies
CMS findings for Holly Hall as of Sep 1, 2026, grouped by inspection cycle (3 cycles); each is a requirement inspectors found not met, and Holly Hall may since have corrected or disputed it. Severity letters · Inspection cycles · Care Compare
Most recent cycle (13 deficiencies)
Standard inspection Oct 7, 2025. CMS counts 13 health deficiencies and 2 fire safety deficiencies in this cycle.
Oct 7, 2025 · Standard inspection
13 deficiencies, highest E
F880 · Infection prevention and control program
Requirement cited (CMS): Provide and implement an infection prevention and control program.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Oct 8, 2025
F814 · Garbage disposal
Requirement cited (CMS): Dispose of garbage and refuse properly.
- Severity
- B No actual harm, potential for minimal harm, pattern
- Status
- Correction date Oct 8, 2025
F812 · Food safety and sanitation
Requirement cited (CMS): Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Oct 8, 2025
F779 · Filing X-ray and diagnostic reports
Requirement cited (CMS): Keep signed and dated reports of x-rays and other diagnostic services in the residents record.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Oct 8, 2025
F770 · Timely laboratory services
Requirement cited (CMS): Provide timely, quality laboratory services/tests to meet the needs of residents.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Oct 8, 2025
F761 · Drug labeling and secure storage
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Oct 8, 2025
F760 · No significant medication errors
Requirement cited (CMS): Ensure that residents are free from significant medication errors.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Oct 8, 2025
F759 · Medication error rate under 5 percent
Requirement cited (CMS): Ensure medication error rates are not 5 percent or greater.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Oct 8, 2025
F693 · Feeding tube use and care
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Oct 8, 2025
F692 · Nutrition and hydration
Requirement cited (CMS): Provide enough food/fluids to maintain a resident's health.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Oct 8, 2025
F690 · Bladder, bowel, and catheter care
Requirement cited (CMS): Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Oct 8, 2025
F677 · Help with daily care
Requirement cited (CMS): Provide care and assistance to perform activities of daily living for any resident who is unable.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Oct 8, 2025
F550 · Dignity and the right to exercise rights
Requirement cited (CMS): Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Oct 8, 2025
Previous cycle: 1 deficiency (standard inspection Aug 29, 2024)
Standard inspection Aug 29, 2024. CMS counts 1 health deficiency and 1 fire safety deficiency in this cycle.
Oct 3, 2024 · Complaint inspection
1 deficiency, highest D
F677 · Help with daily care
Requirement cited (CMS): Provide care and assistance to perform activities of daily living for any resident who is unable.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Nov 5, 2024
Earlier cycle: 10 deficiencies (standard inspection Jun 8, 2023)
Standard inspection Jun 8, 2023. CMS counts 10 health deficiencies and 1 fire safety deficiency in this cycle.
Jun 29, 2024 · Complaint inspection
1 deficiency, highest D
F678 · CPR and basic life support
Requirement cited (CMS): Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Aug 14, 2024
Apr 3, 2024 · Complaint inspection
2 deficiencies, highest E
F677 · Help with daily care
Requirement cited (CMS): Provide care and assistance to perform activities of daily living for any resident who is unable.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Apr 24, 2024
F584 · Safe, clean, homelike surroundings
Requirement cited (CMS): 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.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Apr 24, 2024
Jun 8, 2023 · Standard inspection
7 deficiencies, highest E
F812 · Food safety and sanitation
Requirement cited (CMS): Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jul 28, 2023
F758 · Psychotropic drug safeguards
Requirement cited (CMS): 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.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jul 28, 2023
F755 · Pharmacy services and a consultant pharmacist
Requirement cited (CMS): Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jul 28, 2023
F695 · Respiratory and oxygen care
Requirement cited (CMS): Provide safe and appropriate respiratory care for a resident when needed.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jul 28, 2023
F655 · Baseline care plan within 48 hours
Requirement cited (CMS): Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jul 28, 2023
F640 · Submitting assessment data on time
Requirement cited (CMS): Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jul 28, 2023
F552 · Being informed about health and treatment
Requirement cited (CMS): Ensure that residents are fully informed and understand their health status, care and treatments.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jul 28, 2023
Tags cited in more than one inspection
2 tags cited on more than one inspection date at Holly Hall; each date counts once and does not mean the same incident. PNC = past non-compliance.
| Tag | Inspections | Dates |
|---|---|---|
| F677 Help with daily care | 3 | Oct 7, 2025; Oct 3, 2024; Apr 3, 2024 |
| F812 Food safety and sanitation | 2 | Oct 7, 2025; Jun 8, 2023 |
Fines and payment denials
CMS lists no fines or payment denials for this nursing home in the last three years.
Staffing and CMS ratings
- Total nurse staff hours per resident per day
- 4.74 h (above the Texas median of 3.27 h)
- RN hours per resident per day
- 0.56 h (above the Texas median of 0.38 h)
- Weekend nurse staff hours per resident per day
- 4.15 h
- Nursing staff turnover
- 58.7% (Texas median 52.1%)
- Administrators who left
- 0
- CMS overall rating
- 3 of 5
- Health inspection rating
- 3 of 5
- Staffing rating
- 4 of 5
- Quality measure rating
- 4 of 5
CMS figures for Holly Hall, copied as published; Texas medians are ours.
Facility details
- Address
- 2000 Holly Hall St, Houston, TX 77054
- Phone
- (713) 799-9031
- County
- Harris
- Accepts
- Medicare and Medicaid
- Ownership
- For profit - Limited Liability company
- Chain (CMS)
- Not part of a chain in CMS data
- Certified beds
- 62
- Average residents per day
- 37.5
- In Medicare/Medicaid since
- Feb 2, 2012
- Inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- None
- Sprinklers in all required areas
- Yes
Questions to ask on a visit
Based on the tags cited most often here.
- How often do residents who need help get assistance with bathing, grooming, and mouth care? (F677, cited 3 times)
- When was the kitchen last inspected, and how are food temperatures checked? (F812, cited 2 times)
- How do staff learn about and respect each resident's personal routines and choices? (F550, cited 1 time)
- How do doctors and nurses explain changes in treatment to residents and their families? (F552, cited 1 time)
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Houston · 43 deficiencies - Paradigm at Westbury
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Source
CMS Provider Data Catalog: Provider Information, Health Deficiencies, Penalties, Survey Summary. Processed by CMS Sep 1, 2026; next update Oct 28, 2026.