Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Holly Hall
Houston, TX · 62 certified beds · Last Life Safety survey October 7, 2025
CMS Certification Number 676306 · first certified February 2012
Also on this campus
The same campus holds a state-licensed assisted living facility, with its own state record on the Assisted Living Index: Holly Hall (2000 Holly Hall St). Matched by the telephone number the two records share. The records are separate and are never added together.
Ownership
Independently operated (no chain recorded by CMS) · For profit - Limited Liability company
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within TX
4 citations — more than 20% of the 1,177 certified nursing homes in TX. Compared within TX rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 2 citations; the earlier surveys in the window averaged 1. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens November 2026 — about 2 months from now. This facility’s last Life Safety survey was October 2025. Facilities in TX are typically surveyed 13–14 months after the last one (median 14), measured over 1,905 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
Get an email about Holly Hall
One email when it happens. No account; stop it any time with one click.
Physical environment (health survey)
2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 4 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in TX, and nationally. Surveyors differ markedly between states, so the TX figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 4 |
| Median facility in TX | 7 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| June 8, 2023 | 1 |
| August 29, 2024 | 1 |
| October 7, 2025 | 2 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | 1 | 2024-08-29 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 1 | 2025-10-07 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2023-06-08 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2025-10-07 |
What the citations cover
- Smoke Deficiencies 4
| Category | Citations |
|---|---|
| Smoke Deficiencies | 4 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
October 7, 2025 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 1, 2025) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (October 1, 2025) |
August 29, 2024 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (October 7, 2024) |
June 8, 2023 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (July 21, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.