SHENANDOAH CENTER

50 MULBERRY TREE STREET
CHARLES TOWN, WV, 25414
3047241101
CCN: 515167
1
Overall
1
Health
2
Staffing
4
Quality
ChainGENESIS HEALTHCARE
Special FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
Ownership
NameRole%
GENESIS WV HOLDINGS LLC5% OR GREATER DIRECT OWNERSHIP INTEREST100%
FC-GEN OPERATIONS INVESTMENT LLC5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
GEN OPERATIONS I LLC5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
GEN OPERATIONS II LLC5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
GENESIS HEALTHCARE INC5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
GENESIS HEALTHCARE LLC5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
GENESIS HOLDINGS LLC5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
GENESIS OPERATIONS LLC5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
GHC HOLDINGS LLC5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
HCCF MANAGEMENT GROUP XI LLC5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
SUN HEALTHCARE GROUP INC5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
SUNDANCE REHABILITATION HOLDCO INC5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
ZAC PROPERTIES XI LLC5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
FISHMAN, STEVEN5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
WHITMAN, ARNOLD5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
WELLTOWER OP LLC5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
BERG, MICHAELCORPORATE OFFICERNOT APPLICABLE
BRIDGEFORD, LAURACORPORATE OFFICERNOT APPLICABLE
MENDELSON, AVICORPORATE OFFICERNOT APPLICABLE
ALBAUGH, MIRANDAOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
BURNER, EILISHOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
Penalties (1)
DateTypeAmount
2024-07-26Fine$17K
Health Deficiencies (61)
2025-11-06 · Health
D
F657 · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
2024-07-26 · Health
E
F919 · Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
F
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F842 · Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
E
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
E
F761 · Pharmacy Service Deficiencies
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.
J
F760 · Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
E
F758 · Pharmacy Service Deficiencies
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
E
F730 · Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
D
F725 · Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
K
F698 · Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
E
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
D
F688 · Quality of Life and Care Deficiencies
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
D
F679 · Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
G
F677 · Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
D
F657 · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
E
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
D
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
D
F623 · Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
J
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
E
F584 · Resident Rights Deficiencies
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.
E
F583 · Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
E
F561 · Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
2023-06-14 · Health
D
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
2023-03-01 · Health
D
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
D
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
2022-09-30 · Health
F
F885 · Infection Control Deficiencies
Report COVID19 data to residents and families.
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
E
F838 · Administration Deficiencies
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
E
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
E
F809 · Nutrition and Dietary Deficiencies
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
E
F804 · Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
E
F803 · Nutrition and Dietary Deficiencies
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.
E
F802 · Nutrition and Dietary Deficiencies
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
E
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
E
F732 · Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
F
F727 · Nursing and Physician Services Deficiencies
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
F
F725 · Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
E
F698 · Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
D
F697 · Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
D
F695 · Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
E
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
E
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
D
F657 · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
D
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
D
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
D
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
D
F561 · Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
2019-11-20 · Health
F
F881 · Infection Control Deficiencies
Implement a program that monitors antibiotic use.
F
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
F
F867 · Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
D
F842 · Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
E
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F
F756 · Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
E
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
D
F692 · Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
D
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
D
F679 · Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
D
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
D
F655 · Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
D
F558 · Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day
3.03
3.68
RN Hrs/Resident/Day
0.87
0.54
LPN Hrs/Resident/Day
0.40
0.81
CNA Hrs/Resident/Day
1.75
2.33
PT Hrs/Resident/Day
0.07
0.12
Data as of 2026-03-01