Holbrook Healthcare Center
183 Holbrook Road, Buckhannon, WV 26201
Holbrook Healthcare Center is a nursing home in Buckhannon, West Virginia. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating1 of 5
- Last standard health inspectionJuly 29, 2025 (1 year ago)
- Health citations since April 6, 202242 (West Virginia average 40)
- Fines in the past three years2, $79,108 in total
- CMS flagsNone listed by CMS
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CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
CMS update of April 29, 2026
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
CMS update of February 25, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
Fine
CMS changed the fine from July 29, 2025 from $29,140 to $18,941.
CMS update of January 14, 2026
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5.
CMS update of November 20, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
CMS update of July 30, 2025
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
Health inspection on July 29, 2025
18 citationsCMS lists this as a standard inspection and a complaint inspection.
Severity K is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
18 of 123 West Virginia homes (15%) got a citation at the immediate jeopardy level in 2025.
CMS fine of $18,941 on July 29, 2025.
Show the 18 citations
Citation F0807. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
CMS lists it as corrected on September 3, 2025.
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on September 3, 2025.
CMS has cited this home for F0584 2 times since 2023.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on September 3, 2025.
CMS has cited this home for F0812 3 times since 2023.
Citation F0842. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on September 3, 2025.
CMS has cited this home for F0842 2 times since 2023.
Citation F0552. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are fully informed and understand their health status, care and treatments.
CMS lists it as corrected on September 3, 2025.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on September 3, 2025.
CMS has cited this home for F0580 2 times since 2023.
Citation F0628. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
CMS lists it as corrected on September 3, 2025.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on September 3, 2025.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on September 3, 2025.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on September 3, 2025.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on September 3, 2025.
Citation F0693. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on September 3, 2025.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on September 3, 2025.
Citation F0770. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely, quality laboratory services/tests to meet the needs of residents.
CMS lists it as corrected on September 3, 2025.
Citation F0806. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
CMS lists it as corrected on September 3, 2025.
CMS has cited this home for F0806 2 times since 2022.
Citation F0810. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
CMS lists it as corrected on September 3, 2025.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on September 3, 2025.
CMS has cited this home for F0880 2 times since 2022.
Citation F0881. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Implement a program that monitors antibiotic use.
CMS lists it as corrected on September 3, 2025.
Fire safety inspection on July 29, 2025
3 citationsCMS lists this as a standard inspection.
Show the 3 citations
Citation K0353. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on August 11, 2025.
Citation K0372. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on August 11, 2025.
CMS has cited this home for K0372 2 times since 2023.
Citation K0511. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on August 11, 2025.
CMS has cited this home for K0511 2 times since 2023.
CMS update of April 30, 2025
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 1 of 5 to 4 of 5.
CMS update of February 26, 2025
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
CMS abuse icon
CMS removed its abuse icon from this home.
CMS update of August 29, 2024
Fine
CMS changed the fine from December 28, 2023 from $92,565 to $60,167.
CMS update of July 31, 2024
Star rating
The CMS quality measures star rating changed from 1 of 5 to 2 of 5.
CMS update of June 26, 2024
Special Focus Facility
CMS no longer lists this home as a Special Focus Facility candidate.
CMS update of April 25, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS health inspection star rating changed from 4 of 5 to 1 of 5.
Special Focus Facility
CMS now lists this home as a Special Focus Facility candidate.
CMS abuse icon
CMS added its abuse icon to this home.
CMS update of January 31, 2024
Star rating
The CMS overall star rating changed from 4 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 1 of 5.
Health inspection on December 28, 2023
6 citationsCMS lists this as a complaint inspection.
Severity K is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
6 of 123 West Virginia homes (5%) got a citation at the immediate jeopardy level in 2023.
CMS fine of $60,167 on December 28, 2023.
Show the 6 citations
Citation F0607. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS lists it as corrected on February 22, 2024.
Citation F0610. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on February 22, 2024.
CMS has cited this home for F0610 2 times since 2022.
Citation F0600. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on February 22, 2024.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on February 22, 2024.
CMS has cited this home for F0609 2 times since 2022.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on March 5, 2024.
Citation F0698. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS lists it as corrected on March 5, 2024.
CMS update of December 21, 2023
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 4 of 5.
Health inspection on October 10, 2023
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on October 24, 2023.
Health inspection on August 9, 2023
11 citationsCMS lists this as a standard inspection.
Show the 11 citations
Citation F0803. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on September 1, 2023.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on September 1, 2023.
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on September 1, 2023.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on September 1, 2023.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on September 1, 2023.
Citation F0623. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS lists it as corrected on September 1, 2023.
Citation F0640. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
CMS lists it as corrected on September 1, 2023.
Citation F0645. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
PASARR screening for Mental disorders or Intellectual Disabilities
CMS lists it as corrected on September 1, 2023.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on September 1, 2023.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on September 1, 2023.
Citation F0868. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
CMS lists it as corrected on September 1, 2023.
Fire safety inspection on August 9, 2023
5 citationsCMS lists this as a standard inspection.
Show the 5 citations
Citation K0372. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on October 2, 2023.
Citation K0374. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on October 2, 2023.
Citation K0923. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on October 2, 2023.
Citation K0321. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on October 2, 2023.
Citation K0511. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on October 2, 2023.
Health inspection on April 6, 2022
6 citationsCMS lists this as a standard inspection.
Show the 6 citations
Citation F0578. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on May 3, 2022.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on May 3, 2022.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on May 3, 2022.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
The home is disputing this citation through CMS's independent review.
CMS lists it as corrected on May 3, 2022.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
The home is disputing this citation through CMS's independent review.
CMS lists it as corrected on May 3, 2022.
Citation F0806. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
CMS lists it as corrected on May 3, 2022.
Fire safety inspection on April 6, 2022
4 citationsCMS lists this as a standard inspection.
Show the 4 citations
Citation K0351. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install an approved automatic sprinkler system.
CMS lists it as corrected on May 10, 2022.
Citation K0921. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that testing and maintenance of electrical equipment is performed.
CMS lists it as corrected on May 10, 2022.
Citation K0918. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on May 10, 2022.
Citation K0926. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
CMS lists it as corrected on May 10, 2022.
CMS star ratings
- 1 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 1 of 5CMS staffing star rating
- 4 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (304) 472-3280
- Last standard health inspection
- July 29, 2025 (1 year ago)
- Certified beds
- 110
- Residents per day, on average
- 103.2
- Ownership type
- For profit - Corporation
- Legal business name
- Holbrook Leasing Co LLC
- Chain
- Communicare Health
- Takes part in
- Medicare and Medicaid
More health citations than the West Virginia average (42 vs 40).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- HEALTH CARE LEASE FACILITIES, LLC5% or greater direct ownership interest · 100% · since 12/01/2019
- HOLBROOK MGT CO., LLCOperational/managerial control · not applicable · since 12/01/2019
- MALONE, JAMESOperational/managerial control · not applicable · since 09/01/2021
- SLOAN-OLIVERIO, ALYSSAOperational/managerial control · not applicable · since 09/23/2024
Questions
When was Holbrook Healthcare Center last inspected?
CMS lists July 29, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Holbrook Healthcare Center have?
CMS lists 42 health citations since April 6, 2022. CMS also calls these deficiencies.
Has Holbrook Healthcare Center been fined?
CMS lists 2 fines in the past three years, $79,108 in total.
What is the CMS star rating of Holbrook Healthcare Center?
Its CMS overall star rating is 1 of 5.
Is Holbrook Healthcare Center a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.