Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Holly Hall during CMS and state inspections, most recent first.
A resident with ALS did not receive scheduled showers or bed baths, leading to poor hygiene and hospital admission with wounds and cerumen impaction. Despite being dependent on staff for all ADLs, there was no documentation of care provided, and family members expressed concerns about the handling of the resident's BIPAP mask. Facility staff acknowledged the lack of documentation and care, which was deemed unacceptable by the DON and Administrator.
A resident with a DNR order was given CPR due to a documentation error in their electronic medical record. The DNR form was placed in a separate Hospice binder instead of being uploaded to the electronic record, leading to CPR being administered during an emergency. The facility's policy requires advance directives to be prominently displayed in the medical record, which was not followed.
A facility failed to maintain a clean and safe environment for three residents. A resident's shower had dried fecal matter and a urine odor, another resident's room was cluttered with clothes and shoes, and a third resident's room had a strong urine odor. These deficiencies were observed despite the residents' care plans requiring staff assistance for daily living activities. Interviews with staff confirmed the issues, indicating a lack of adherence to facility standards.
The facility failed to provide necessary hygiene care for two residents who were unable to perform activities of daily living. One resident, with multiple medical conditions, was found with a wet adult brief and a urine smell, indicating a lack of timely care. Another resident, with severe cognitive impairment, did not receive scheduled showers, as evidenced by limited documentation and a strong urine odor in the room. Staff interviews revealed inconsistencies in performing these tasks, which were acknowledged by the DON.
Failure to Provide Adequate ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident diagnosed with Amyotrophic Lateral Sclerosis, who was dependent on staff for all ADLs, including personal hygiene. The resident did not receive scheduled showers or bed baths for a significant period, as documented between late August and late September. Despite being scheduled for showers three times a week, there was no documentation to support that these were provided, and the resident was found to have poor hygiene upon hospital admission. The resident was admitted to the hospital with a dislodged G-tube and was diagnosed with aspiration pneumonia. Upon examination, the resident was noted to have wounds on the nose, ears, and hands, as well as cerumen impaction, indicating poor hygiene. Interviews with family members revealed concerns about the resident's care, particularly regarding the handling of the resident's BIPAP mask and the roughness of staff during care, which contributed to the resident's refusal of some bed baths. Interviews with facility staff indicated a lack of consistent documentation and communication regarding the resident's care refusals and hygiene needs. The facility's Director of Nursing and Administrator acknowledged the deficiencies in care and documentation, noting that the lack of proper hygiene and documentation was unacceptable. The facility's policy on giving bed baths was not followed, as evidenced by the absence of documentation and the resident's condition upon hospital admission.
Failure to Honor DNR Order Due to Documentation Error
Penalty
Summary
The facility failed to ensure that personnel provided basic life support, including CPR, in accordance with physician orders and the resident's advance directives. A resident with metastatic cholangiocarcinoma, who was receiving hospice services and required total assistance for ADLs, was admitted with a physician-signed DNR order. However, this DNR order was not documented in the resident's electronic medical record. During an emergency situation, the resident was found unresponsive, and CPR was initiated by RN B, as the DNR status was not visible in the electronic record. Paramedics continued CPR upon arrival until the DNR form was found in the Hospice binder, at which point CPR was stopped. The incident revealed a breakdown in the facility's procedure for handling advance directives. The DNR form, brought in by the resident's family, was placed in a separate Hospice binder instead of being uploaded to the electronic medical record. The Director of Nursing (DON) acknowledged that the failure to document the DNR status in the electronic record could lead to residents not having their end-of-life preferences honored. The facility's policy on advance directives requires that such information be prominently displayed in the medical record, which was not adhered to in this case.
Facility Fails to Maintain Clean and Safe Environment for Residents
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for three residents, as observed during a survey. Resident #1's shower was found to have dried fecal matter on the floor and wall, and a urine odor was present. This resident, who has a history of heart failure, Alzheimer's disease, type 2 diabetes, and essential hypertension, requires assistance with activities of daily living, including bathing and toileting. The care plan indicated that the resident is dependent on staff for these tasks, yet the shower area was not maintained in a sanitary condition. Resident #2's room was observed to be cluttered with a bag of clothes and shoes on the floor. This resident, who has a diagnosis of malignant neoplasm of connective tissue and gait abnormalities, expressed that she was unable to manage housework and had requested assistance to organize her belongings. Despite this, the clutter remained, indicating a lack of attention to her needs for a clean and organized living space. Resident #3's room was noted to have a strong urine odor during multiple observations. This resident, with a history of acute cerebrovascular insufficiency, cognitive communication deficit, sepsis, and acute respiratory failure, has a care plan that includes regular checks for incontinence. However, the persistent odor suggests that these checks and necessary interventions were not adequately performed. Interviews with staff, including the DON and the facility administrator, confirmed the issues and highlighted a reliance on agency staff who may not have been fulfilling their responsibilities effectively.
Failure to Provide Adequate Hygiene Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to perform activities of daily living, specifically in maintaining good nutrition, grooming, and personal and oral hygiene. Resident #1, a [AGE] year-old with diagnoses including heart failure, Alzheimer's disease, type 2 diabetes, and essential hypertension, was observed to have a urine smell and a wet adult brief that was not changed in a timely manner. Despite being dependent on staff for toileting hygiene and frequently incontinent, the resident's brief was not checked or changed as needed, as confirmed by observations and interviews with the resident's responsible party. Resident #3, an [AGE] year-old with severe cognitive impairment and other medical conditions, was also not provided with scheduled showers, as evidenced by the limited documentation of showers in the electronic medical record. The resident's room had a strong urine odor, indicating a lack of proper hygiene care. Interviews with staff, including a contract nurse and a CNA, revealed that CNAs were responsible for changing briefs and providing showers, but these tasks were not consistently performed. The DON acknowledged the issue and noted that it was both the nurses' and CNAs' responsibility to ensure residents received appropriate care.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Houston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Garden Terrace Healthcare Center Of Houston | 0.7 mi | — | 3 | 1 |
| The Methodist Hospital Snf | 1.8 mi | — | 0 | 0 |
| Bayou Manor | 2.6 mi | — | 3 | 0 |
| Avir At Orem | 4.3 mi | — | 0 | 0 |
| Paradigm At Westbury | 4.6 mi | — | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.