Holbrook Healthcare Center
183 Holbrook Road · Buckhannon, WV · 26201 · 3044723280
120 certified beds For profit - Corporation Chain: Communicare Health
Why this verdict
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (1 citation).
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $18,941 in fines in the last 24 months.
- Inspection results have improved across recent cycles.
Red flags
1 immediate-jeopardy citation in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
3 abuse-related citations at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 1 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 3.45 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.31 | 0.55–0.75 |
| Weekend hours / resident-day | 3.09 | ≈ weekday level |
| Nursing turnover / year | 33% | median 45% |
| Fines (3-yr window) | 2 · $79,108 |
Inspection citations (42 in the current record)
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Immediate jeopardy · K July 29, 2025
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected September 3, 2025 · Nutrition and Dietary
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Potential for harm · D July 29, 2025
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected September 3, 2025 · Resident Rights
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Potential for harm · E July 29, 2025
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.
Corrected September 3, 2025 · Resident Rights
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Potential for harm · D July 29, 2025
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected September 3, 2025 · Resident Rights
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Potential for harm · D July 29, 2025
Ensure each resident receives an accurate assessment.
Corrected September 3, 2025 · Resident Assessment and Care Planning
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Potential for harm · D July 29, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected September 3, 2025 · Resident Assessment and Care Planning
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Potential for harm · D July 29, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected September 3, 2025 · Quality of Life and Care
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Potential for harm · D July 29, 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.
Corrected September 3, 2025 · Quality of Life and Care
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Potential for harm · D July 29, 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.
Corrected September 3, 2025 · Pharmacy Service
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Potential for harm · D July 29, 2025
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected September 3, 2025 · Administration
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Potential for harm · D July 29, 2025
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected September 3, 2025 · Nutrition and Dietary
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Potential for harm · D July 29, 2025
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected September 3, 2025 · Nutrition and Dietary
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Potential for harm · E July 29, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected September 3, 2025 · Nutrition and Dietary
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Potential for harm · E July 29, 2025
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected September 3, 2025 · Resident Assessment and Care Planning
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Potential for harm · D July 29, 2025
Provide and implement an infection prevention and control program.
Corrected September 3, 2025 · Infection Control
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Potential for harm · D July 29, 2025
Implement a program that monitors antibiotic use.
Corrected September 3, 2025 · Infection Control
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Potential for harm · D July 29, 2025 · found via complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected September 3, 2025 · Resident Rights
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Potential for harm · D July 29, 2025 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected September 3, 2025 · Quality of Life and Care
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Immediate jeopardy · J December 28, 2023 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected February 22, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Immediate jeopardy · K December 28, 2023 · found via complaint
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected February 22, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Immediate jeopardy · K December 28, 2023 · found via complaint
Respond appropriately to all alleged violations.
Corrected February 22, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 28, 2023 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected February 22, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 28, 2023 · found via complaint
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected March 5, 2024 · Quality of Life and Care
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Potential for harm · D December 28, 2023 · found via complaint
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected March 5, 2024 · Quality of Life and Care
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Potential for harm · E October 10, 2023 · found via complaint
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected October 24, 2023 · Nutrition and Dietary
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| July 29, 2025 | Fine | $18,941 |
| December 28, 2023 | Fine | $60,167 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 515076 · certified since September 4, 1984. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.