Holbrook Healthcare Center

In the surveyor’s words

From the most serious findings on record at Holbrook Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, patternF807Jul 29, 2025

  Based on observation, record review, staff interview and resident review, the facility failed to provide liquids in the correct consistency to meet the resident's individual needs. This was true for three (3) of seven (7) residents that were ordered nectar and honey thickened liquids. This failed practice had the potential to affect a limited number of residents. Resident identifiers: #7, #82, and #31. Facility Census: 107.Findings included: a) On 07/21/2024, Residents #7, #82, and #31 were observed to liquids at bedside that were not nectar or honey consistency during the investigation process. This failed practice created an immediate jeopardy situation.During the initial resident interview process, Resident #7 received thin liquids with the lunch meal in a spouted cup. […]

• Immediate jeopardy, patternF607Dec 28, 2023

  Based on staff interview and record review, the facility failed to implement their written Abuse and Neglect policy as it related to reporting allegations of abuse and failed to follow procedures to investigate any such allegations. Their lack of action to investigate the abuse allegation placed Resident #1 at continued risk of staff abuse for six (6) days prior to Surveyor intervention. Review of facility records found that there were 30 other residents who had a BIMS (Brief Interview for Mental Status) score between 0-7, suggesting severe cognitive impairment. They also were at risk of staff abuse. Resident identifiers: #1, #3, #6, #10, #13, #14, #17, #26, #34, #36, #37, #38, #44, #49, #50, #53, #55, #57, #60, #66, #67, #68, #75, #87, #89, #95, #97, #99, #103, #104, #111. […]

• Immediate jeopardy, patternF610Dec 28, 2023

  Based on record review and staff interview, the facility failed to complete a thorough investigation of a staff member's allegation of resident abuse, maintain documentation that alleged violation was thoroughly investigated, and report the results to Adult Protective Services and the State Survey Agency, within five (5) working days of the incident in accordance with State law. The facility's failure to complete a thorough investigation of a staff member's allegation of resident abuse left residents who were deemed to be severely cognitively impaired at risk of further abuse. In addition, the facility failed to ensure the victim was protected from further abuse which put the residents at risk for additional serious harm and or death. […]

• Immediate jeopardy, isolatedF600Dec 28, 2023

  Based on policy review, record review, and staff interview, the facility failed to protect a resident's right to be free from abuse that resulted in mental anguish for Resident #1. This was a random opportunity for a discovery made during a complaint investigation. Resident identifier: #1. Facility census: 107. Using the reasonable person concept, the facility's failure to protect a resident's right to be free from abuse resulted in mental anguish for Resident #1 and had the potential to cause serious harm and or death. This was true for Resident #1. Facility Census: 107. […]

• No harm, potential for more than minimal, patternF584Jul 29, 2025

  Based on observation, resident interview and staff interview, the facility failed to provide a homelike dining experience for residents served in the main dining room and to ensure resident areas were clean and odor free. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident Identifiers: #90 and #5. Facility Census: 107. Findings included: a) On 07/21/2025 at 12:30 PM, during the Dining Room Observation, no tablecloths were on the tables in the main dining room and the residents were served their meals on plastic trays from the kitchen. […]