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.

4
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
0
Tags cited more than once
Across separate surveys
4
Inspection & testing records
Of the citations on file

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

Slippingmore citations at the latest survey than at its earlier surveys in the window.

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

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Which alerts

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

  • F-0880 Provide and implement an infection prevention and control program.
  • F-0584 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.

How that compares

Citations on file over three years

Compared with the median facility in TX, and nationally. Surveyors differ markedly between states, so the TX figure is the meaningful one.

This facility4TX median7National median11
Citations on file over three years, compared
MeasureCitations
This facility4
Median facility in TX7
Median facility nationally11

Survey history

Citations at each Life Safety survey
12023-0612024-0822025-10
Citations at each Life Safety survey
Survey dateCitations
June 8, 20231
August 29, 20241
October 7, 20252

Most-cited tags

Most-cited tags at this facility
K-03241K-03551K-03451K-03531
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0324Provide properly protected cooking facilities.12024-08-29
K-0355Properly select, install, inspect, or maintain portable fire extinguishes.12025-10-07
K-0345Have approved installation, maintenance and testing program for fire alarm systems.12023-06-08
K-0353Inspect, test, and maintain automatic sprinkler systems.12025-10-07

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 4
Citations by CMS category
CategoryCitations
Smoke Deficiencies4

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

October 7, 2025 — 2 citations

Citations issued on October 7, 2025
TagWhat the surveyor checksStatus
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (October 1, 2025)
K-0355Properly select, install, inspect, or maintain portable fire extinguishes.Deficient, Provider has date of correction (October 1, 2025)

August 29, 2024 — 1 citation

Citations issued on August 29, 2024
TagWhat the surveyor checksStatus
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (October 7, 2024)

June 8, 2023 — 1 citation

Citations issued on June 8, 2023
TagWhat the surveyor checksStatus
K-0345Have 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.