About Holly Hall
Holly Hall, located in Houston, TX, is a for-profit organization that accepts Medicare and Medicaid.
Why Families Choose Holly Hall
- More Nursing Time: Staff spends 4.52 hours per resident daily (National Avg: 3.87).
Key Performance Indicators
- CMS Overall Rating 3 Stars
- Nursing Hours 4.52 hrs
- Safety Record Clean
Chain Affiliations & Network
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Nursing Staff Analysis
Staffing levels are a critical indicator of quality care. We analyze the daily hours of care provided by Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs).
Above Average Staffing
Holly Hall provides more care hours than the state average and more than the national average.
Registered Nurses (RN)
Licensed Practical Nurses
Certified Assistants
CMS Quality Ratings
| Category | Rating | Stars |
|---|---|---|
| Overall Rating | 3 |
|
| Health Inspection | 3 |
|
| Quality Measures | 4 |
|
| Staffing | 3 |
|
Health Inspection History
| Inspection Cycle | Score | Date |
|---|---|---|
| Cycle 1 (Most Recent) | 76 | Oct 07, 2025 |
| Weighted Average | 74 | Combined Score |
Detailed Quality Measures
Rates are from CMS quality measures (claims-based and MDS-based) for the reporting period ending May 01, 2026. Some measures may be omitted when CMS does not report a numeric rate for this facility.
Medicare claims-based measures
Typically includes short-stay outcomes, hospitalizations, and ED use from Medicare claims.
| Measure | Rate |
|---|---|
| Percentage of short-stay residents who were rehospitalized after a nursi... (QM521) | 32.0% |
| Percentage of short-stay residents who had an outpatient emergency depar... (QM522) | 8.0% |
| Number of hospitalizations per 1000 long-stay resident days (QM551) | N/A |
| Number of outpatient emergency department visits per 1000 long-stay resi... (QM552) | N/A |
MDS-based measures
Resident assessment data; often used for long-stay care quality.
| Measure | Rate |
|---|---|
| Percentage of long-stay residents whose need for help with daily activit... (QM401) | 19.1% |
| Percentage of long-stay residents who lose too much weight (QM404) | 0.0% |
| Percentage of long-stay residents with a catheter inserted and left in t... (QM406) | 0.0% |
| Percentage of long-stay residents with a urinary tract infection (QM407) | 1.7% |
| Percentage of long-stay residents who have depressive symptoms (QM408) | 0.0% |
| Percentage of long-stay residents who were physically restrained (QM409) | 0.0% |
| Percentage of long-stay residents experiencing one or more falls with ma... (QM410) | 0.0% |
| Percentage of long-stay residents assessed and appropriately given the p... (QM415) | 60.0% |
| Percentage of short-stay residents assessed and appropriately given the... (QM430) | 58.4% |
| Percentage of short-stay residents who newly received an antipsychotic m... (QM434) | 0.0% |
| Percentage of long-stay residents whose ability to walk independently wo... (QM451) | N/A |
| Percentage of long-stay residents who received an antianxiety or hypnoti... (QM452) | 3.7% |
| Percentage of long-stay residents assessed and appropriately given the s... (QM454) | N/A |
| Percentage of short-stay residents who were assessed and appropriately g... (QM472) | 40.4% |
| Percentage of long-stay residents with pressure ulcers (QM479) | 10.1% |
| Percentage of long-stay residents with new or worsened bowel or bladder... (QM480) | 27.0% |
| Percentage of long-stay residents who received an antipsychotic medicati... (QM481) | N/A |
Complaints & Deficiencies
Complaint History by Year
This chart shows the number of complaints filed each year.
Summary:
- 2023: 7 complaints
- 2024: 4 complaints
- Total: 11 complaints on record
Recent Complaints (Since Jan 2023)
| Date | Description |
|---|---|
| Nov 05, 2024 | Provide care and assistance to perform activities of daily living for any resident who is unable. |
| Aug 14, 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. |
| 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. |
| Apr 24, 2024 | Provide care and assistance to perform activities of daily living for any resident who is unable. |
| Jul 28, 2023 | Ensure that residents are fully informed and understand their health status, care and treatments. |
| Jul 28, 2023 | Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. |
| Jul 28, 2023 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted |
| Jul 28, 2023 | Provide safe and appropriate respiratory care for a resident when needed. |
| Jul 28, 2023 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. |
| 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. |
| Jul 28, 2023 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. |
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Owner & Operator Information
Business Entity
HOLLY HALL
Ownership Structure
Management & Direction
- AUTUMN CLOUSE CORPORATE DIRECTOR
- PETER DREW CORPORATE OFFICER
- PETER DREW OPERATIONAL/MANAGERIAL CONTROL
- HOLLY HALL OPERATIONAL/MANAGERIAL CONTROL
Associated Doctors
Local Comparison
| Facility | Distance | Rating |
|---|---|---|
| The Methodist Hospital Snf | N/A | 5 |
| Mrc The Crossings | N/A | 5 |
| Park Manor of Cyfair | N/A | 5 |
| Ignite Medical Resort Webster, LLC | N/A | 5 |
| Oak Bend Medical Center | N/A | 5 |
| Bayou Manor | N/A | 5 |
| Paradigm at The Brazos | N/A | 5 |
| The Vosswood Nursing Center | N/A | 4 |
| East View Healthcare | N/A | 5 |
| The Hallmark | N/A | 5 |
Related Analysis
Best Nursing Homes in Houston, TX
Compare Holly Hall to the top-rated facilities in the area.
Ownership Details
Complete list of registered owners, including direct and indirect ownership.
Noted Deficiencies
Detailed history of deficiencies with descriptions and correction dates.
Nursing Hours Analysis
Detailed breakdown of staffing hours per resident by role.
Frequently Asked Questions
- Skilled Nursing Care: 24/7 medical supervision and complex medical treatments
- Long-term Residential Care: Assistance with daily living activities for extended stays
- Short-term Rehabilitation: Recovery services after hospital stays or surgeries
- Memory Care: Specialized programs for residents with dementia and Alzheimer's disease
- Level of care needed (skilled nursing vs. long-term care)
- Room type (private vs. semi-private)
- Insurance coverage (Medicare, Medicaid, private insurance)
- Length of stay and specific services required
For current rates and to discuss payment options, contact Holly Hall directly at 7137999031. Their admissions team can help determine coverage and out-of-pocket expenses.
Environment & Cleanliness
- Overall cleanliness and odors
- Resident room conditions
- Common area maintenance
- Safety features and accessibility
Staff & Care Quality
- Staff-to-resident ratios
- How staff interact with residents
- Response time to resident needs
- Staff knowledge and professionalism
Ask to speak with current residents and their families, tour at different times of day, and review the facility's most recent inspection reports.