Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Holbrook Healthcare Center during CMS and state inspections, most recent first.
Incorrect Liquid Consistency Provided to Residents on Thickened Liquids: Three residents with orders for nectar- or honey-thick liquids were observed receiving thin liquids, including water and chocolate milk that did not meet the ordered consistency. An NA confirmed one resident was allowed thin liquids, an LPN removed regular water from another resident’s tray, and an NA confirmed the third resident’s drink was thin rather than honey thick.
The facility failed to provide a homelike dining experience and to keep resident areas clean and odor free. Residents were served lunch on plastic trays in the main dining room with no tablecloths on the tables, and an LPN said tablecloths are usually taken off when present. A resident reported her bedpan box was not being cleaned and that odors sometimes came into her room from the bathroom; staff observed a strong odor, visible yellow and brownish residue in the bedpan container, and a black substance around the commode base.
Food items were found improperly stored in the kitchen, a nutrition station, and a nutrition pantry. Surveyors observed sausage patties, hoagie buns, fries, baked beans, sandwiches, a cheeseburger, and jelly packets that were not sealed, labeled, or dated as required, and staff confirmed the findings. The facility policy stated that dry goods should be date marked as appropriate and cold foods should be stored in covered containers, labeled, and dated.
Incomplete and inaccurate resident records were identified for multiple residents. Issues included POST forms signed by a MPOA/POA even though residents had capacity, a missing diet order in the chart, a POST update based on verbal consent without the updated signature, no documented monitoring order for Eliquis side effects, and an EHR diagnosis list that omitted major depressive disorder despite provider notes documenting it.
The facility failed to notify the MPOA of a resident's dermatology appointment and did not document this notification, resulting in the MPOA learning of the appointment from the doctor's office. Additionally, the facility did not notify the physician or responsible party of a change in condition following a CT scan for another resident, with no documentation of such notifications found in the medical record.
A resident with multiple chronic conditions and total dependence on staff for ADLs was found with long, jagged fingernails, despite a care plan requiring staff to provide all personal hygiene. Family and staff interviews, as well as direct observation, confirmed that nail care was not performed as needed.
A resident with dementia, anxiety, Alzheimer's disease, and major depressive disorder was prescribed sertraline and trazodone, but the record contained no informed consent for trazodone. The facility could not produce the consent when asked by the surveyor, and the Regional Operations Coordinator stated it could not be found or was not available, showing the resident or representative was not informed of the risks and benefits of the medication.
A resident with decision-making capacity was emergently transferred to the hospital after reporting emesis and shaking and saying she felt like she did during a prior MI. Record review showed the facility did not provide the required written notice explaining the reason for the transfer or the bed-hold policy and duration, and a Regional Clinical Coordinator confirmed the notifications were not completed or given.
A resident’s MDS was inaccurate because it omitted major depressive disorder from the active diagnoses section. The medical provider had documented generalized anxiety disorder, unspecified dementia with anxiety, and major depressive disorder, recurrent, moderate, but the completed MDS listed Alzheimer’s disease, non-Alzheimer’s dementia, anxiety disorder, and unspecified dementia with anxiety instead. The Regional Operations Coordinator acknowledged the diagnosis should have been included.
Failure to care plan for PTSD: A resident with chronic PTSD and depression was observed withdrawn and sitting alone outside his room. The EHR showed the care plan had no focus, goal, or interventions for PTSD, and there was little documentation of trauma-informed or culturally competent care aside from a social history assessment noting the resident was unaware of PTSD triggers. The RCC confirmed PTSD was not care planned.
A resident with a history of a right gluteal fold pressure ulcer returned from the hospital and was documented on admission as having no skin areas noted, even though the wound was later identified as a stage 3 PI and a new DTI was also noted. The facility did not assess the pressure ulcers on readmission until several days later, despite its policy to evaluate skin condition upon return from the hospital.
Tube Feeding Placement Checked After Initial Flush: An LPN was observed giving a bolus tube feeding to a resident with a G-tube and initially flushed the tube before verifying placement, despite orders to check placement before each feeding and flush. The LPN then aspirated gastric contents, replaced them, verified placement using air and a stethoscope, and completed the bolus feed and post-feed flush.
Improper storage of a refrigerated medication was identified during a medication cart inspection on the 400 hall. An unopened bottle of Latanoprost labeled to refrigerate was found in the med cart instead of being stored under refrigeration, and the medication insert confirmed it should be kept at 2 to 8 C (36 to 46 F) and protected from light. An LPN confirmed the finding.
A resident’s ordered lab work was not completed as directed by the physician. The resident had orders for a CBC with diff, CMP, and lipid panel on a set schedule, but the February lab testing was not done as ordered and was later completed in May instead. The RCC confirmed the missed ordered labs during survey review.
A resident’s documented food dislikes were not honored, as staff served repeated meals containing items the resident said he did not like, including pickles, mayonnaise, vinegar, fish, egg salad, and tartar sauce. The resident told the surveyor he had reported these dislikes to staff, but the dietary record in Mealtracker showed no preferences marked, and the DM stated the system was not crossing over from the EHR.
A resident did not receive ordered adaptive eating utensils with the meal tray. The tray card listed a left angled fork, left angled spoon, plate guard, and Kennedy cup, but the fork and spoon were missing. The resident stated the equipment was not provided with meals, and a NA confirmed the utensils were not on the tray.
A Nurse Aide failed to wear a gown while providing Foley catheter care to a resident on EBP. Signs outside the room indicated that gown and gloves were required for direct resident care, but the aide only donned gloves and proceeded with care. When asked about EBP, the aide acknowledged not putting on a gown and then donned one before continuing care.
Antibiotic stewardship was not followed for a resident with a toe amputation surgical site infection and MRSA. The resident was treated with multiple antibiotics, including linezolid, tigecycline, and later doxycycline, even though prior wound cultures and sensitivities showed resistance to those agents, and there was no documentation explaining the change from linezolid to doxycycline.
Incorrect Liquid Consistency Provided to Residents on Thickened Liquids
Penalty
Summary
The facility failed to provide liquids in the correct consistency to meet residents’ individual needs for three residents who were ordered thickened liquids. Resident #7 had a diet order for dysphagia puree texture with nectar-thick liquids and spout cups, but during observation was given thin liquids with lunch in a spouted cup and also had a mug with a straw containing ice water on the tray table. Nursing assistant #12 confirmed both cups contained thin liquids and stated, "I think she's allowed to have some thin liquids." Resident #82 had a diet order for dysphagia mechanical texture with honey-thick liquids and spout cups, but was observed with three drinks on the tray table, including one cup with a lid and straw containing water. The clinical manager removed the water and stated he was not supposed to have regular water. Resident #31 had a diet order for dysphagia puree texture with honey-thick liquids, but during observation the chocolate milk did not appear honey thickened; the liquid ran off a spoon without residue, and nursing assistant #3 confirmed it was thin and not honey thickened. The facility’s diet and nutrition care manual stated that all liquids should be thickened to the proper consistency, including water and other beverages.
Homelike Dining and Bathroom Cleanliness Deficiencies
Penalty
Summary
The facility failed to provide a homelike dining experience in the main dining room and failed to keep resident areas clean and odor free. During a dining room observation, residents were eating lunch on plastic trays from the kitchen, and no tablecloths were on the tables; an LPN confirmed the residents were eating on trays and stated that when there are tablecloths, they usually take them off. For Resident #90, the resident reported that staff do not clean her bedpan box and said the smell sometimes comes into her room from the bathroom. In the resident’s bathroom, a white plastic standing box containing a bedpan was observed with a strong odor, and the bedpan and the bottom of the container had yellow and brownish substance present. The resident stated housekeeping had cleaned it about a month earlier when she asked. A black substance was also observed around the base of the commode, and an LPN confirmed the odor in the bathroom.
Food Items Stored Without Required Labels or Dates
Penalty
Summary
Food was not stored in accordance with professional standards in the kitchen, Nutrition Station 100-200, and Nutrition Pantry 300-400 Hall. During the kitchen investigation, surveyors found sausage patties in a bag that was not sealed and had no use-by date, four bags of hoagie buns that were not labeled and had no use-by date, crinkle cut fries in a bag that was not labeled, and baked beans in a plastic container with no use-by date. The Regional Dietary Manager confirmed these items and stated, "I didn't know you had to label if you know what it is." Surveyors also found two bologna and cheese sandwiches that were not labeled and had no use-by date, a cheeseburger that was not sealed and had no use-by date, and individual packets of Smucker's concord grape jelly with no open or use-by date. These items were confirmed by the Regional Director of Operations and an LPN. The facility's Food Storage policies stated that dry goods should be date marked as appropriate and that cold foods should be stored, wrapped, or in covered containers, labeled and dated.
Incomplete and inaccurate resident records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for 6 of 36 residents reviewed. For one resident, a capacity form signed by the FNP stated the resident had capacity, yet the POST form was signed by the resident’s MPOA instead of the resident. The Administrator confirmed the POST form was signed by the MPOA even though the resident had capacity, and the facility policy stated the center would assess decision-making ability and approach the health care proxy or legal representative only if the resident was determined not to have decision-making capacity. A similar issue was identified for another resident whose POST form was signed by the POA even though the resident had been determined capacitated to make her own decisions. Additional record review found a resident with no diet order on the chart or on the facility’s Order Listing Report, despite a Speech Therapy order for an Informed Dining Consent Form changing the diet to regular with regular liquids and a later diet order being added. Another resident had a verbal consent from the responsible party for a POST update, but an updated POST form with the responsible party’s signature was not obtained. For one resident receiving Eliquis 5 mg twice daily for clot prevention, the chart, MAR, and TAR did not show an order for monitoring side effects for the anticoagulant, and monitoring was not being done. For another resident, the EHR listed several diagnoses, but provider progress notes also documented major depressive disorder, which was not included on the diagnosis list, leaving the diagnosis list incomplete and inaccurate.
Failure to Notify MPOA and Responsible Parties of Appointments and Changes in Condition
Penalty
Summary
The facility failed to notify the Medical Power of Attorney (MPOA) of a resident's scheduled dermatology appointment and did not document this notification in the medical record. The MPOA only became aware of the appointment after being contacted by the doctor's office for treatment permission. A grievance was filed by the MPOA regarding the lack of notification, and review of the medical record confirmed there was no documentation indicating the MPOA was informed of the new appointment. Staff interviews confirmed that notification should be documented in the medical record, but no such documentation was found for this event. The resident involved lacked capacity due to dementia and had a DNR order with limited interventions. Additionally, the facility failed to notify the physician and responsible party of a change in condition for another resident who underwent a CT scan. There was no documentation in the electronic medical chart indicating that the physician, resident, or responsible party had been notified of the results. Staff confirmed the absence of documentation for these notifications. The facility's policy requires notification of changes in condition, but this was not followed in these instances.
Failure to Provide ADL Nail Care to Dependent Resident
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care to a dependent resident, as evidenced by multiple observations and interviews. The resident, who has a significant ADL self-care performance deficit due to a complex medical history including progressive vascular leukoencephalopathy, multiple sclerosis, dementia, depression, arthritis, and other conditions, was found to have long and jagged fingernails on both hands. The resident's care plan indicated total dependence on staff for personal hygiene, including nail care, with staff responsible for performing all related tasks. During a family interview, the Medical Power of Attorney reported that the resident's fingernails were consistently untrimmed during visits, sometimes causing indentations in the resident's hands. This observation was confirmed by a surveyor and acknowledged by an LPN, who agreed that the resident's fingernails needed to be cut. Record review further supported that the resident required full assistance with ADLs, yet the necessary nail care was not provided as required by the care plan.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to inform the resident or the resident's representative of the risks and benefits associated with a prescribed psychotropic medication for one resident reviewed during the annual survey. Resident #77 had diagnoses including unspecified dementia, generalized anxiety disorder, Alzheimer's disease, and major depressive disorder noted in provider progress notes, and the medical provider ordered sertraline for depression and trazodone for insomnia. Review of the medical record found no informed consent for trazodone, and when the surveyor asked for the record, the facility did not provide it before the survey ended. The following day, the Regional Operations Coordinator stated that the consent could not be found or was not available, confirming that the facility did not have documentation that the resident or representative had been informed of the risks and benefits of trazodone.
Missing Transfer and Bed-Hold Notifications
Penalty
Summary
The facility failed to provide required discharge documentation when Resident #104 was emergently transferred to the hospital after reporting emesis and shaking and stating she felt like she did when she previously had a myocardial infarction. The resident had capacity to make her own medical decisions. Record review showed no written notification to the resident explaining the reasons for the transfer and no notice of the facility's bed-hold policy or its duration. A Regional Clinical Coordinator confirmed that there was no evidence the written transfer/discharge notification or bed-hold notification had been completed and provided to the resident at the time of transfer.
MDS Omitted Major Depressive Disorder Diagnosis
Penalty
Summary
The facility failed to maintain accuracy of the MDS Resident Assessment and Care Screening for Resident #77 by omitting a diagnosis of major depressive disorder from Section I - Active Diagnoses. Record review showed the resident’s mental health-related diagnoses included unspecified dementia, mild with anxiety, generalized anxiety disorder, and Alzheimer’s disease. The medical provider documented generalized anxiety disorder, unspecified dementia, mild, with anxiety, and major depressive disorder, recurrent, moderate in progress notes dated 03/16/25 and 06/10/25. The MDS was last completed on 06/17/25, but Section I listed Alzheimer’s disease, non-Alzheimer’s dementia, anxiety disorder, and unspecified dementia, mild, with anxiety, and did not include major depressive disorder. During interview, the Regional Operations Coordinator acknowledged that major depressive disorder should have been included in the MDS.
Failure to Care Plan for PTSD
Penalty
Summary
The facility failed to develop a personalized care plan for a resident with diagnoses of chronic Post-Traumatic Stress Disorder (PTSD) and unspecified depression. During an interview, the resident was observed sitting alone in his wheelchair outside his bedroom door and appeared very withdrawn with a face void of emotion; after speaking for several minutes, he stated he had served two deployments with the Army in Iraq and later smiled once before the conversation ended. Review of the electronic health record showed the resident was admitted on 04/18/25 with PTSD and depression, and the care plan dated 04/17/25 did not include any focus, goal, or interventions/tasks for PTSD. Aside from a Social History Assessment completed by the Director of Social Services on 05/06/25 stating the resident was unaware of triggers for his PTSD, there was little documentation of facility efforts to provide trauma-informed care or culturally competent care. The Regional Clinical Coordinator confirmed that PTSD was not care planned for the resident.
Pressure Ulcer Assessment and Monitoring Failure
Penalty
Summary
The facility failed to ensure residents did not develop preventable pressure ulcers and failed to ensure residents with pressure ulcers received assessment in accordance with professional standards of practice. The deficiency involved Resident #110, whose records showed an unstageable pressure ulcer of the right gluteal fold first assessed when the resident returned from a hospital transfer on 03/08/25. That wound later became a stage IV pressure ulcer and remained present through 07/07/25, when the resident was transferred to the hospital. When Resident #110 returned to the facility on 07/14/25, the Nursing Admission Evaluation documented no skin areas noted. However, a Nurse Practitioner note on 07/17/25 stated the resident was being seen for evaluation of a stage 3 pressure injury of the right gluteal fold and noted a deep tissue injury of the left inner thigh that was present on admission from 07/14/25. The facility’s policy stated resident skin condition would be evaluated upon return from the hospital, but the pressure ulcers present on readmission were not assessed until 07/17/25, as confirmed by the Regional Clinical Coordinator on 07/23/25.
Tube Feeding Placement Checked After Initial Flush
Penalty
Summary
The facility failed to provide tube feeding care and services within established acceptable standards of care for Resident #2, who had physician orders for enteral feedings five times a day and for flushing the gastrostomy tube with 30 mL of water before and after each bolus feed. The resident also had orders to check G-tube placement by aspiration immediately after insertion, before each feeding and/or flush, before administering medications via tube, before performing gastric residual checks, and at least every 8 hours, as well as to validate tube placement by aspirating 15-30 cc of stomach contents with a 60 cc catheter-tipped syringe before accessing the tube. During observation on 07/28/25, an LPN was seen administering a bolus tube feeding and first flushed the resident’s gastrostomy tube with approximately 30 cc of water before checking placement. The LPN then stated she should have checked placement before flushing, aspirated approximately 60 cc of mustard-colored fluid from the tube, replaced the gastric contents, and used air insufflation with a stethoscope to verify placement. After verifying placement, the LPN administered the bolus feeding and flushed the tube again with water.
Improper Storage of Refrigerated Medication
Penalty
Summary
Medication storage was found to be improper during a random observation on the 400 hall medication cart. On 07/23/2025 at 10:10 AM, surveyors found an unopened bottle of Latanoprost in the medication cart even though the label stated "REFRIGERATE." The medication insert indicated that unopened bottles should be stored under refrigeration at 2 to 8 C (36 to 46 F) and protected from light. This finding was confirmed by an LPN.
Laboratory Testing Not Completed as Ordered
Penalty
Summary
The facility failed to ensure laboratory testing was completed according to physician orders for Resident #10. The resident had orders dated 01/15/25 for a complete blood cell count with differentiation and comprehensive metabolic panel every six months in February and August, as well as a lipid panel annually in February. Review of the resident’s laboratory results showed that the ordered testing was not performed in February 2025. During interview on 07/24/2025, the Regional Clinical Coordinator confirmed that Resident #10 did not receive the physician-ordered laboratory testing in February 2025 and stated that the testing was instead completed on 05/22/25.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor a resident’s food preferences and dislikes. Resident #45 told the surveyor that the food was not too good and that he had been served too many items with vinegar, including repeated egg salad sandwiches and brussel sprouts, and stated he did not like pickles or other foods with vinegar. He also stated he had told staff about these dislikes. The resident’s EHR listed preferences and dislikes including gravy on the side and dislikes of pickles, mayonnaise, vinegar, and fish of any kind. Meal ticket review showed the resident was served multiple foods that conflicted with those documented dislikes, including BBQ cheeseburger with a pickle spear, egg salad sandwich, fish sandwich with tartar sauce, fried fish with tartar sauce, breaded fish on a bun with tartar sauce, cheeseburger on a bun with pickle, and fried fish with tartar sauce across the two weeks reviewed. The Dietary Manager stated the department used Mealtracker to know resident preferences, but the requested Mealtracker document for this resident had no preferences marked. When the surveyor pointed out the mismatch between the meal tickets and the EHR dislikes, the Dietary Manager stated the Mealtracker system was apparently not crossing over from the EHR, and the Dietary Manager and Regional Dietary Coordinator said they had found this issue in a few residents and thought something happened when the menu changed from Winter/Spring to Summer.
Ordered Adaptive Eating Utensils Not Provided
Penalty
Summary
The facility failed to ensure Resident #5 had the ordered adaptive eating utensils. During observation of the resident’s meal tray, the tray card indicated a left angled fork, left angled spoon, plate guard, and Kennedy cup were ordered, but the left angled fork and left angled spoon were not present on the lunch tray. When asked whether the equipment was provided with meals, Resident #5 stated that it was not and said she kept a set of fork and spoon in her room, which aides washed in her bathroom with dishwashing soap. A NA confirmed there was no left angled fork or spoon on the tray.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when a Nurse Aide failed to don a gown while performing Foley catheter care for Resident #44, who was on Enhanced Barrier Precautions. On 07/28/25 at 10:39 AM, Resident #44 was observed receiving catheter care from NA #84. Signs posted outside the room indicated that Enhanced Barrier Precautions were required for direct resident care, including catheter care, and that gown and gloves were to be worn. NA #84 donned gloves and proceeded with the catheter care but did not put on a gown. When asked about Enhanced Barrier Precautions, NA #85 stated, "Oh no. I didn't put on a gown," then immediately donned a gown and continued changing the resident's brief and disposing of soiled items.
Antibiotic Stewardship Failure With Resistant MRSA Treatment
Penalty
Summary
The facility failed to follow principles of antibiotic stewardship for Resident #66, who was admitted with a surgical site infection at the site of a toe amputation. After increased drainage was noted at the wound site, a culture was obtained and the resident was started on cefalexin. The wound culture grew Methicillin-resistant Staphylococcus aureus (MRSA), and the sensitivity report showed resistance to clindamycin, tetracycline, doxycycline, and methicillin (oxacillin). Despite this, the resident was later started on linezolid for MRSA even though the prior wound culture and sensitivity showed the organism was resistant to linezolid. Resident #66 was later transferred to the hospital due to tissue necrosis at the prior amputation site, where a wound culture again showed MRSA with resistance to clindamycin, tetracycline, and doxycycline, in addition to methicillin (oxacillin). During hospitalization, the resident was started on intravenous tigecycline even though the wound culture and sensitivity had shown resistance to tigecycline. After readmission to the facility, she continued tigecycline, then received linezolid again, and was later prescribed doxycycline by mouth for surgical site infection without documentation explaining the change from linezolid to doxycycline. The Regional Clinical Coordinator confirmed the resident was started on doxycycline despite prior cultures showing resistance to doxycycline and could not provide additional information about the antibiotic change.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Buckhannon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St. Joseph's Hospital | 0.8 mi | ★★★★★ | 0 | 0 |
| Crestview Manor Healthcare | 13 mi | ★★★★★ | 4 | 0 |
| Mansfield Place | 14.7 mi | ★★★★★ | 0 | 0 |
| Tygart Valley Health & Rehabilitation | 14.8 mi | ★★★★★ | 12 | 0 |
| Autumn Lake Healthcare At Crystal Springs | 18 mi | ★★★★★ | 3 | 0 |
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