| Holly Hall | |
| 2000 Holly Hall St, Houston, Texas 77054 | |
| (713) 799-9031 | |
| Name | Holly Hall |
|---|---|
| Location | 2000 Holly Hall St, Houston, Texas |
| Certified By | Medicare and Medicaid |
| No. of Certified Beds | 62 |
| Occupancy Rate | 60.48% |
| Medicare ID (CCN) | 676306 |
| Legal Business Name | Holly Hall |
| Ownership Type | For Profit - Limited Liability Company |
| NPI Number | 1760603229 |
| Match | Confirmed listed in Medicare enrollment records |
| Organization Name | Holly Hall |
| Address | 2000 Holly Hall St, Houston, TX 77054 |
| Phone Number | 713-799-9031 |
| Ratings from Surveys (Inspections): | |
| Ratings from Quality Measures: | |
| Ratings from Staffing Data: | |
| Overall Rating: |
|---|
| Staffing Measure | Provider | National Avg. |
|---|---|---|
| Total nurse staff hours per resident per day | 4.74 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.56 | 0.69 |
| Licensed practical nurse (LPN) hours per resident per day | 1.45 | 0.86 |
| Nurse aide hours per resident per day | 2.73 | 2.32 |
| Total nurse staff hours per resident per day on the weekend | 4.15 | 3.42 |
| RN hours per resident per day on the weekend | 0.43 | 0.48 |
| Physical therapist hours per resident per day | 0.17 | 0.07 |
| Total nursing staff turnover | 58.7% | 45.8% |
| Registered nurse turnover | 40% | 42.9% |
| Number of administrators who have left the nursing home | 0 | 0.5 |
| Cited for abuse, neglect or exploitation of residents (Care Compare abuse icon) | No |
| Number of Fines | 0 |
| Total Amount of Fines in Dollars | $0 |
| Number of Payment Denials | 0 |
| Total Number of Penalties | 0 |
| Date | Deficiency | Harm Level | Status |
|---|---|---|---|
| Oct 7, 2025 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. F0550, Resident Rights, Standard inspection | Potential for harm, pattern | Corrected by Oct 8, 2025 |
| Oct 7, 2025 | Provide care and assistance to perform activities of daily living for any resident who is unable. F0677, Quality of Life and Care, Standard inspection | Potential for harm, pattern | Corrected by Oct 8, 2025 |
| Oct 7, 2025 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. F0690, Quality of Life and Care, Standard inspection | Potential for harm, pattern | Corrected by Oct 8, 2025 |
| Oct 7, 2025 | Provide enough food/fluids to maintain a resident's health. F0692, Quality of Life and Care, Standard inspection | Potential for harm, pattern | Corrected by Oct 8, 2025 |
| Oct 7, 2025 | Ensure medication error rates are not 5 percent or greater. F0759, Pharmacy Service, Standard inspection | Potential for harm, pattern | Corrected by Oct 8, 2025 |
| Oct 7, 2025 | Ensure that residents are free from significant medication errors. F0760, Pharmacy Service, Standard inspection | Potential for harm, pattern | Corrected by Oct 8, 2025 |
| Oct 7, 2025 | Keep signed and dated reports of x-rays and other diagnostic services in the residents record. F0779, Administration, Standard inspection | Potential for harm, pattern | Corrected by Oct 8, 2025 |
| Oct 7, 2025 | 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. F0693, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Oct 8, 2025 |
| Oct 7, 2025 | 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. F0761, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Oct 8, 2025 |
| Oct 7, 2025 | Provide timely, quality laboratory services/tests to meet the needs of residents. F0770, Administration, Standard inspection | Potential for harm, isolated | Corrected by Oct 8, 2025 |
| Oct 7, 2025 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812, Nutrition and Dietary, Standard inspection | Potential for harm, isolated | Corrected by Oct 8, 2025 |
| Oct 7, 2025 | Provide and implement an infection prevention and control program. F0880, Infection Control, Standard inspection | Potential for harm, isolated | Corrected by Oct 8, 2025 |
| Oct 7, 2025 | Dispose of garbage and refuse properly. F0814, Nutrition and Dietary, Standard inspection | Minimal harm potential, pattern | Corrected by Oct 8, 2025 |
| Oct 3, 2024 | Provide care and assistance to perform activities of daily living for any resident who is unable. F0677, Quality of Life and Care, Complaint inspection | Potential for harm, isolated | Corrected by Nov 5, 2024 |
| Jun 29, 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. F0678, Quality of Life and Care, Complaint inspection | Potential for harm, isolated | Corrected by Aug 14, 2024 |
| Apr 3, 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. F0584, Resident Rights, Complaint inspection | Potential for harm, pattern | Corrected by Apr 24, 2024 |
| Apr 3, 2024 | Provide care and assistance to perform activities of daily living for any resident who is unable. F0677, Quality of Life and Care, Complaint inspection | Potential for harm, pattern | Corrected by Apr 24, 2024 |
| Jun 8, 2023 | Ensure that residents are fully informed and understand their health status, care and treatments. F0552, Resident Rights, Standard inspection | Potential for harm, pattern | Corrected by Jul 28, 2023 |
| Jun 8, 2023 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted F0655, Resident Assessment and Care Planning, Standard inspection | Potential for harm, pattern | Corrected by Jul 28, 2023 |
| Jun 8, 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. F0758, Pharmacy Service, Standard inspection | Potential for harm, pattern | Corrected by Jul 28, 2023 |
| Jun 8, 2023 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812, Nutrition and Dietary, Standard inspection | Potential for harm, pattern | Corrected by Jul 28, 2023 |
| Jun 8, 2023 | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. F0640, Resident Assessment and Care Planning, Standard inspection | Potential for harm, isolated | Corrected by Jul 28, 2023 |
| Jun 8, 2023 | Provide safe and appropriate respiratory care for a resident when needed. F0695, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Jul 28, 2023 |
| Jun 8, 2023 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. F0755, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Jul 28, 2023 |
| Quality Measure | Provider | National Avg. |
|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.15 | 13.87 |
| Percentage of long-stay residents who lose too much weight | 0 | 5.19 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.62 | 0.82 |
| Percentage of long-stay residents with a urinary tract infection | 1.69 | 1.59 |
| Percentage of long-stay residents who have depressive symptoms | 0 | 12.8 |
| Percentage of long-stay residents who were physically restrained | 0 | 0.13 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0 | 3.23 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 73.77 | 93.55 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.17 | 82.04 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0 | 1.56 |
| Percentage of long-stay residents whose ability to walk independently worsened | Not Available | 14.07 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 3.57 | 19.52 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Not Available | 95.46 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 40.41 | 79.75 |
| Percentage of long-stay residents with pressure ulcers | 11.21 | 4.62 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.05 | 19.01 |
| Percentage of long-stay residents who received an antipsychotic medication | 0 | 15.38 |
Afton Oaks Nursing and Rehabilitation Center Location: 7514 Kingsley St, Houston, Texas 77087 Phone: (713) 644-8393 |