Holbrook Healthcare Center
183 Holbrook Road, Buckhannon, WV 26201 · Upshur County · 120 certified beds · avg 107 residents/day · certified since Sep 4, 1984
Part of chain: COMMUNICARE HEALTH (110 facilities, chain avg rating 3.2★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · Jul 29, 2025 · F-0807
The facility did not provide residents with enough to drink, or with drinks matching their needs and preferences, to keep them properly hydrated.
Why it matters: Dehydration develops quickly in older adults and can cause confusion, urinary infections, and hospitalization.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Sep 3, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Dec 28, 2023 · F-0607 · triggered by a complaint
The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection.
Why it matters: Without working prevention policies, mistreatment is more likely to happen and less likely to be caught.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Feb 22, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Dec 28, 2023 · F-0610 · triggered by a complaint
The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do.
Why it matters: When allegations aren't investigated, harm to residents can continue unchecked.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Feb 22, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Dec 28, 2023 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Feb 22, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (42)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jul 29, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not provide residents with enough to drink, or with drinks matching their needs and preferences, to keep them properly hydrated. |
| Jul 29, 2025 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Jul 29, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jul 29, 2025 | E · Potential for harm, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Jul 29, 2025 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Jul 29, 2025 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Jul 29, 2025 | D · Potential for harm, one-off | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). |
| Jul 29, 2025 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Jul 29, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jul 29, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Jul 29, 2025 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Jul 29, 2025 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Jul 29, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jul 29, 2025 | D · Potential for harm, one-off | The facility did not provide timely, quality laboratory tests to meet residents' needs. |
| Jul 29, 2025 | D · Potential for harm, one-off | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. |
| Jul 29, 2025 | D · Potential for harm, one-off | The facility did not provide special eating equipment and utensils — like adaptive cups or easy-grip silverware — for residents who need them, along with appropriate help at meals. |
| Jul 29, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jul 29, 2025 | D · Potential for harm, one-off | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| Dec 28, 2023 | ▲ K · Immediate jeopardy, repeated | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| Dec 28, 2023 | ▲ K · Immediate jeopardy, repeated | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Dec 28, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Dec 28, 2023 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Dec 28, 2023 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint |
| Dec 28, 2023 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. · from a complaint |
| Oct 10, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Aug 9, 2023 | E · Potential for harm, repeated | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Aug 9, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Aug 9, 2023 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Aug 9, 2023 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Aug 9, 2023 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Aug 9, 2023 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Aug 9, 2023 | D · Potential for harm, one-off | The facility did not enter each resident's assessment information into the required format and send it to the state within 7 days of completing the assessment, as the rules require. |
| Aug 9, 2023 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Aug 9, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Aug 9, 2023 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Aug 9, 2023 | C · Minimal risk, facility-wide | The facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months. |
| Apr 6, 2022 | E · Potential for harm, repeated | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Apr 6, 2022 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 6, 2022 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Apr 6, 2022 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Apr 6, 2022 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| Apr 6, 2022 | D · Potential for harm, one-off | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (11 → 18).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 6 | 0 | E |
| 2023 | 18 | 3 | K ▲ |
| 2025 | 18 | 1 | K ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $79,108.
| Date | Type | Amount / length |
|---|---|---|
| Jul 29, 2025 | Fine | $18,941 |
| Dec 28, 2023 | Fine | $60,167 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | West Virginia avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.22 | 3.55 | 3.95 | bottom 40% in West Virginia; bottom 23% in the U.S. |
| Registered Nurse hours | 0.25 | 0.70 | 0.69 | bottom 1% in West Virginia; bottom 5% in the U.S. |
| Weekend total nurse staffing | 2.84 | 3.07 | 3.50 | bottom 41% in West Virginia; bottom 22% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.15 | 0.40 | 0.48 | bottom 3% in West Virginia; bottom 5% in the U.S. |
| Total nursing staff turnover (%) | 32.9 | 44.1 | 45.8 | top 17% in West Virginia; top 20% in the U.S. |
| RN turnover (%) | 62.5 | 42.4 | 42.9 | bottom 18% in West Virginia; bottom 19% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.35, RN 0.26, weekend 2.96. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 4/5 · short-stay residents: 3/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Health Care Lease Facilities, LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 12/01/2019 |
| C.R. Stoltz Family Investment Company INC | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2019 |
| C.R. Stoltz Irrevocable Trust | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2019 |
| Groves, Donna | Individual | Corporate Officer | NOT APPLICABLE | 12/01/2019 |
| Health Care Lease Facilities, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2019 |
| Holbrook Mgt Co., LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 12/01/2019 |
| Holbrook Mgt Co., LLC | Organization | ADP of the SNF | NOT APPLICABLE | 06/25/2025 |
| I. Rosedale Irrevocable Trust | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2019 |
| Malone, James | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2021 |
| Malone, James | Individual | ADP of the SNF | NOT APPLICABLE | 09/01/2021 |
| Odenthal, Richard | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 05/08/2025 |
| R.S. Wilheim Irrevocable Trust | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2019 |
| Romeo, Dominic | Individual | Corporate Officer | NOT APPLICABLE | 04/01/2023 |
| Ronald S Wilheim 2012 Spousal Trust | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2019 |
| Rosedale Family Investment Company, INC | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2019 |
| RRW, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2019 |
| S.L. Rosedale Irrevocable Trust | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2019 |
| Skilled HC Holdings, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2019 |
| Sloan-Oliverio, Alyssa | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/23/2024 |
| Sloan-Oliverio, Alyssa | Individual | ADP of the SNF | NOT APPLICABLE | 09/23/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure residents — especially those who can't ask — get enough fluids throughout the day?"
- "What specific steps do you take to prevent abuse and neglect, and how are staff trained on them?"
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "How do you keep residents' medical records accurate, complete, and secure?"
- "How do you explain health changes and treatment options to residents and their families?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| St. Joseph's Hospital | 0.8 mi | Buckhannon, WV | ★★★★★ | 5/5 | |
| Crestview Manor Healthcare | 13.0 mi | Jane Lew, WV | ★★★★☆ | 4/5 | |
| Mansfield Place | 14.7 mi | Philippi, WV | ★★★★☆ | 4/5 | |
| Tygart Valley Health & Rehabilitation | 14.8 mi | Belington, WV | ★★★☆☆ | 3/5 | |
| Autumn Lake Healthcare at Crystal Springs | 18.0 mi | Elkins, WV | ★☆☆☆☆ | 2/5 | |
| Nella's at Autumn Lake Healthcare | 18.0 mi | Elkins, WV | ★☆☆☆☆ | 1/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 515076.