Map showing the location of Holly Hall in Houston, Texas
2000 Holly Hall St, Houston, TX, 77054

Overall Score

CMS Five-Star Quality Rating
3/5AverageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • TexasAbove only 45% of peers1,167 rated homes · average 2.8★
  • Harris CountyAbove only 45% of peers94 rated homes · average 2.8★
  • United StatesAbove only 41% of peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point3★+0.2 vs TX avg
  • StaffingCan add or remove a star3★+0.9 vs TX avg
  • Quality measuresCan add or remove a star4★+0.2 vs TX avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles3★Above only 46% of peersTX avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover3★Above 69% of peersTX avg2.1★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments4★Above only 37% of peersTX avg3.8★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff4.53hrsTop 5%TX avg3.40Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.54hrsAbove 79% of peersTX avg0.44Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better55%Above only 36% of peersTX avg51%RN turnover70%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$0Above 71% of peersTX avg$55,368Fines · denials0 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
24citations
5inspection dates
0actual harm (G–I)
0immediate jeopardy (J–L)
Oct 7, 2025most recent

Citations by monthJun 2023 – Oct 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Oct 7, 202513 citationsCycle 1worst E · no actual harm
  1. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryD · isolatedCorrected Oct 8, 2025
  2. F814Dispose of garbage and refuse properly.Nutrition and DietaryB · patternCorrected Oct 8, 2025
  3. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Oct 8, 2025
  4. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsE · patternCorrected Oct 8, 2025
  5. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareE · patternCorrected Oct 8, 2025
  6. F690Provide 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 CareE · patternCorrected Oct 8, 2025
  7. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareE · patternCorrected Oct 8, 2025
  8. F693Ensure 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 CareD · isolatedCorrected Oct 8, 2025
  9. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceE · patternCorrected Oct 8, 2025
  10. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceE · patternCorrected Oct 8, 2025
  11. F761Ensure 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 ServiceD · isolatedCorrected Oct 8, 2025
  12. F770Provide timely, quality laboratory services/tests to meet the needs of residents.AdministrationD · isolatedCorrected Oct 8, 2025
  13. F779Keep signed and dated reports of x-rays and other diagnostic services in the residents record.AdministrationE · patternCorrected Oct 8, 2025
Oct 3, 20241 citationCycle 2worst D · no actual harm
  1. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Nov 5, 2024
Jun 29, 20241 citationCycle 2worst D · no actual harm
  1. 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 CareD · isolatedCorrected Aug 14, 2024
Apr 3, 20242 citationsCycle 2worst E · no actual harm
  1. F584Honor 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 RightsE · patternCorrected Apr 24, 2024
  2. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareE · patternCorrected Apr 24, 2024
Jun 8, 20237 citationsCycle 3worst E · no actual harm
  1. F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningE · patternCorrected Jul 28, 2023
  2. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Jul 28, 2023
  3. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Jul 28, 2023
  4. F758Implement 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 ServiceE · patternCorrected Jul 28, 2023
  5. Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.Resident Assessment and Care PlanningD · isolatedCorrected Jul 28, 2023
  6. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Jul 28, 2023
  7. F552Ensure that residents are fully informed and understand their health status, care and treatments.Resident RightsE · patternCorrected Jul 28, 2023

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined4.53hrsTop 5%+1.13 vs TX avg
  • Registered nursesRN hours only0.54hrsAbove 79% of peers+0.10 vs TX avg
  • Licensed practical nursesLPN hours1.38hrs
  • Nurse aidesCNA hours2.61hrs
  • Weekend nursingAll staff on Saturdays and Sundays3.84hrs
  • Texas average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better55%Above only 36% of peersTX avg 51%
  • RN turnoverRegistered nurses only70%Not ranked by CMS
  • Administrators who leftIn the past year0Stable leadership
  • Occupancy62 certified beds · ~36 residents a day59%Above only 31% of peersTX avg 67%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $0In fines
  • 0Fines
  • 0Payment denials
  • $55,368TX avg in fines
Above 71% of peersFewer fines than 71% of rated homes in Texas

Actions on record

No fines or payment denialsNothing on record in the current reporting window. Texas facilities average 1.8 penalties.

Ownership

As filed with CMS

Structure

Ownership type
For profit - Limited Liability company
Chain
Independent
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Operational or managerial control
  • Holly Hall
  • Peter Drew
Corporate directors
  • Autumn Clouse
Corporate officers
  • Peter Drew

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 676306 · 2000 Holly Hall St, Houston, TX, 77054.
  • Percentiles compare this facility with every rated nursing home in Texas and Harris County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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