All citations for Holbrook Healthcare Center

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Holbrook Healthcare Center

Last standard health inspection on record

July 29, 2025

Showing 1 to 25 of 54 citations

  1. Immediate jeopardy to resident health or safety

    Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.

    Pattern (more than a few residents). CMS level K.

    Health citation F-0807, Nutrition and Dietary Deficiencies. Inspection of July 29, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 3, 2025).

  2. Immediate jeopardy to resident health or safety

    Develop and implement policies and procedures to prevent abuse, neglect, and theft.

    Pattern (more than a few residents). CMS level K.

    Health citation F-0607, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of December 28, 2023. Found during a complaint inspection.

    The home gave a date the problem would be corrected (February 22, 2024).

  3. Immediate jeopardy to resident health or safety

    Respond appropriately to all alleged violations.

    Pattern (more than a few residents). CMS level K.

    Health citation F-0610, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of December 28, 2023. Found during a complaint inspection.

    The home gave a date the problem would be corrected (February 22, 2024).

  4. Immediate jeopardy to resident health or safety

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

    Isolated (one or a few residents). CMS level J.

    Health citation F-0600, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of December 28, 2023. Found during a complaint inspection.

    The home gave a date the problem would be corrected (February 22, 2024).

  5. No harm, with potential for more than minimal harm

    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0372, Smoke Deficiencies. Inspection of August 9, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 2, 2023).

  6. No harm, with potential for more than minimal harm

    Install smoke barrier doors that can resist smoke for at least 20 minutes.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0374, Smoke Deficiencies. Inspection of August 9, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 2, 2023).

  7. No harm, with potential for more than minimal harm

    Have proper medical gas storage and administration areas.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0923, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of August 9, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 2, 2023).

  8. No harm, with potential for more than minimal harm

    Install an approved automatic sprinkler system.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0351, Smoke Deficiencies. Inspection of April 6, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 10, 2022).

  9. No harm, with potential for more than minimal harm

    Ensure that testing and maintenance of electrical equipment is performed.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0921, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of April 6, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 10, 2022).

  10. No harm, with potential for more than minimal harm

    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.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0584, Resident Rights Deficiencies. Inspection of July 29, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 3, 2025).

  11. No harm, with potential for more than minimal harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of July 29, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 3, 2025).

  12. No harm, with potential for more than minimal harm

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0842, Resident Assessment and Care Planning Deficiencies. Inspection of July 29, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 3, 2025).

  13. No harm, with potential for more than minimal harm

    Inspect, test, and maintain automatic sprinkler systems.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0353, Smoke Deficiencies. Inspection of July 29, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 11, 2025).

  14. No harm, with potential for more than minimal harm

    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0372, Smoke Deficiencies. Inspection of July 29, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 11, 2025).

  15. No harm, with potential for more than minimal harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of October 10, 2023. Found during a complaint inspection.

    The home gave a date the problem would be corrected (October 24, 2023).

  16. No harm, with potential for more than minimal harm

    Ensure 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.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0803, Nutrition and Dietary Deficiencies. Inspection of August 9, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 1, 2023).

  17. No harm, with potential for more than minimal harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of August 9, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 1, 2023).

  18. No harm, with potential for more than minimal harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0321, Smoke Deficiencies. Inspection of August 9, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 2, 2023).

  19. No harm, with potential for more than minimal harm

    Honor 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.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0578, Resident Rights Deficiencies. Inspection of April 6, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 3, 2022).

  20. No harm, with potential for more than minimal harm

    Provide and implement an infection prevention and control program.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0880, Infection Control Deficiencies. Inspection of April 6, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 3, 2022).

  21. No harm, with potential for more than minimal harm

    Have generator or other power source capable of supplying service within 10 seconds.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0918, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of April 6, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 10, 2022).

  22. No harm, with potential for more than minimal harm

    Ensure that residents are fully informed and understand their health status, care and treatments.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0552, Resident Rights Deficiencies. Inspection of July 29, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 3, 2025).

  23. No harm, with potential for more than minimal harm

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0580, Resident Rights Deficiencies. Inspection of July 29, 2025. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (September 3, 2025).

  24. No harm, with potential for more than minimal harm

    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0628, Resident Rights Deficiencies. Inspection of July 29, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 3, 2025).

  25. No harm, with potential for more than minimal harm

    Ensure each resident receives an accurate assessment.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0641, Resident Assessment and Care Planning Deficiencies. Inspection of July 29, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 3, 2025).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.