Independent · Federal inspection records, searchable
Not a law firm · Not a government agency
Nursing Home Violations Public inspection data, searchable
Facility profile · CCN 515076

Holbrook Healthcare Center

42 federal citations on record , including 4 at the Immediate Jeopardy level, and 2 federal enforcement actions totaling $79,108.

4 Immediate Jeopardy

Record summary

Federal record · Q1 2026
42
Total citations
36
Last 3 years
4
Actual harm+
2
Federal penalties
$79,108
Total fines
1
Overall ★ rating

Most common violation categories here

Resident Rights10 Nutrition & Dietary8 Care Planning6 Quality of Care6 Abuse & Neglect6

Most common F-tags at this facility

F8123 F5842 F8062 F8422 F8802

Citation history

42 on record
SurveyF-TagViolationSeveritySource
Jul 29, 2025F677Provide care and assistance to perform activities of daily living for any resident who is unable.DComplaint
Jul 29, 2025F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.DComplaint
Jul 29, 2025F881Implement a program that monitors antibiotic use.DStandard
Jul 29, 2025F880Provide and implement an infection prevention and control program.DStandard
Jul 29, 2025F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.EStandard
Jul 29, 2025F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.EStandard
Jul 29, 2025F810Provide special eating equipment and utensils for residents who need them and appropriate assistance.DStandard
Jul 29, 2025F807Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.KStandard
Jul 29, 2025F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.DStandard
Jul 29, 2025F770Provide timely, quality laboratory services/tests to meet the needs of residents.DStandard
Jul 29, 2025F761Ensure 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.DStandard
Jul 29, 2025F693Ensure 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.DStandard
Jul 29, 2025F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.DStandard
Jul 29, 2025F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.DStandard
Jul 29, 2025F641Ensure each resident receives an accurate assessment.DStandard
Jul 29, 2025F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.DStandard
Jul 29, 2025F584Honor 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.EStandard
Jul 29, 2025F552Ensure that residents are fully informed and understand their health status, care and treatments.DStandard
Dec 28, 2023F698Provide safe, appropriate dialysis care/services for a resident who requires such services.DComplaint
Dec 28, 2023F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.DComplaint
Dec 28, 2023F610Respond appropriately to all alleged violations.KComplaint
Dec 28, 2023F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.DComplaint
Dec 28, 2023F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.KComplaint
Dec 28, 2023F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.JComplaint
Oct 10, 2023F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.EComplaint
Aug 9, 2023F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyCStandard
Aug 9, 2023F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.DStandard
Aug 9, 2023F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.EStandard
Aug 9, 2023F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.EStandard
Aug 9, 2023F695Provide safe and appropriate respiratory care for a resident when needed.DStandard
Aug 9, 2023F645PASARR screening for Mental disorders or Intellectual DisabilitiesDStandard
Aug 9, 2023F640Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.DStandard
Aug 9, 2023F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.DStandard
Aug 9, 2023F584Honor 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.DStandard
Aug 9, 2023F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.DStandard
Aug 9, 2023F558Reasonably accommodate the needs and preferences of each resident.DStandard
Apr 6, 2022F880Provide and implement an infection prevention and control program.EStandard
Apr 6, 2022F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.DStandard
Apr 6, 2022F610Respond appropriately to all alleged violations.DStandard
Apr 6, 2022F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.DStandard
Apr 6, 2022F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.EStandard
Apr 6, 2022F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.DStandard

Federal enforcement history

Federal regulators have imposed 2 enforcement actions against this facility, including 2 civil money penalties totaling $79,108 .

DateTypeFinePayment denial
Jul 29, 2025Fine$18,941—
Dec 28, 2023Fine$60,167—
About this record A citation is a finding by a state survey team working under federal contract. It is not a court judgment. The description above is drawn verbatim from federal public datasets. Facilities have the right to appeal findings through an Informal Dispute Resolution (IDR/IIDR) process.

Concerned about care at Holbrook Healthcare Center?

An attorney who focuses on nursing-home abuse and neglect can review the facility's record with you — citation patterns, scope/severity levels, complaint-driven findings — and tell you whether the law recognizes what happened.

  • Consultation is free and confidential
  • You pay nothing unless there is a recovery
  • Your note is shared only with vetted plaintiff attorneys
Free · Confidential · Nationwide network
Free Consultation Request
Tell us about your family's situation
A plaintiff attorney will review your note and respond within one business day.