Shenandoah Center
50 Mulberry Tree Street, Charles Town, WV 25414
Shenandoah Center is a nursing home in Charles Town, 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.
CMS star ratings
- 2 of 5CMS overall star rating
- 2 of 5CMS health inspection star rating
- 3 of 5CMS staffing star rating
- 3 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (304) 724-1101
- Last standard health inspection
- March 11, 2026 (8 months ago)
- Certified beds
- 78
- Residents per day, on average
- 75.8
- Ownership type
- For profit - Corporation
- Legal business name
- 50 Mulberry Tree Street Operations LLC
- Chain
- Genesis Healthcare
- Takes part in
- Medicare and Medicaid
More health citations than the West Virginia average (53 vs 40).
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 staffing star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
CMS update of July 29, 2026
Star rating
The CMS quality measures star rating changed from 4 of 5 to 2 of 5.
CMS update of May 27, 2026
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
CMS abuse icon
CMS removed its abuse icon from this home.
8 citations
Health inspection on March 11, 2026
CMS lists this as a standard inspection and a complaint inspection.
Citation F0689. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on April 15, 2026.
CMS has cited this home for F0689 3 times since 2022.
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 April 15, 2026.
CMS has cited this home for F0812 3 times since 2022.
Citation F0835. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
CMS lists it as corrected on April 15, 2026.
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 April 15, 2026.
Citation F0582. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
CMS lists it as corrected on April 15, 2026.
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 April 15, 2026.
Citation F0699. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care or services that was trauma informed and/or culturally competent.
CMS lists it as corrected on April 15, 2026.
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 April 15, 2026.
CMS has cited this home for F0880 3 times since 2022.
1 citation
Fire safety inspection on March 11, 2026
CMS lists this as a standard inspection.
Citation K0331. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Construct fire resistant interior walls.
CMS lists it as corrected on April 1, 2026.
CMS update of November 20, 2025
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 3 of 5 to 4 of 5.
CMS abuse icon
CMS added its abuse icon to this home.
Fine
CMS changed the fine from July 26, 2024 from $48,469 to $10,023.
1 citation
Health inspection on November 6, 2025
CMS lists this as a complaint inspection.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on December 11, 2025.
CMS has cited this home for F0657 3 times since 2022.
CMS update of April 30, 2025
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
CMS update of October 30, 2024
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
CMS update of July 31, 2024
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
22 citations
Health inspection on July 26, 2024
CMS 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.
29 of 123 West Virginia homes (24%) got a citation at the immediate jeopardy level in 2024.
Citation F0698. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS lists it as corrected on September 5, 2024.
CMS has cited this home for F0698 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 November 11, 2023.
Citation F0760. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on September 5, 2024.
Citation F0677. Severity G: actual 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 5, 2024.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on September 5, 2024.
Citation F0561. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
CMS lists it as corrected on September 5, 2024.
CMS has cited this home for F0561 2 times since 2022.
Citation F0583. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Keep residents' personal and medical records private and confidential.
CMS lists it as corrected on September 5, 2024.
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 5, 2024.
Citation F0656. Severity E: potential for more than minimal harm, pattern.
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 5, 2024.
Citation F0689. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on September 5, 2024.
Citation F0730. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Observe each nurse aide's job performance and give regular training.
CMS lists it as corrected on September 5, 2024.
Citation F0758. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on September 5, 2024.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
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 5, 2024.
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 5, 2024.
Citation F0919. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Make sure that a working call system is available in each resident's bathroom and bathing area.
CMS lists it as corrected on September 5, 2024.
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 5, 2024.
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 5, 2024.
CMS has cited this home for F0641 2 times since 2022.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on September 5, 2024.
Citation F0679. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide activities to meet all resident's needs.
CMS lists it as corrected on September 5, 2024.
Citation F0688. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on September 5, 2024.
Citation F0725. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on September 5, 2024.
CMS has cited this home for F0725 2 times since 2022.
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 5, 2024.
5 citations
Fire safety inspection on July 26, 2024
CMS lists this as a standard inspection.
Citation E0039. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on August 26, 2024.
Citation K0211. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on August 26, 2024.
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 August 26, 2024.
Citation K0923. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on August 26, 2024.
Citation K0712. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on August 26, 2024.
CMS has cited this home for K0712 2 times since 2022.
Fine
July 26, 2024 (2 years ago)
CMS fine of $10,023 on July 26, 2024.
Fine
July 26, 2024 (2 years ago)
CMS fine of $13,627 on July 26, 2024.
Fine
July 26, 2024 (2 years ago)
CMS fine of $16,801 on July 26, 2024.
Fine
July 26, 2024 (2 years ago)
CMS fine of $8,018 on July 26, 2024.
CMS update of April 25, 2024
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
22 citations
Health inspection on September 30, 2022
CMS lists this as a standard inspection.
Citation F0725. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on November 1, 2022.
Citation F0727. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on November 1, 2022.
Citation F0885. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Report COVID19 data to residents and families.
CMS lists it as corrected on November 1, 2022.
Citation F0684. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on November 1, 2022.
Citation F0689. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on November 1, 2022.
Citation F0698. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS lists it as corrected on November 1, 2022.
Citation F0732. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on November 1, 2022.
Citation F0755. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on November 1, 2022.
Citation F0802. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
CMS lists it as corrected on November 1, 2022.
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 November 1, 2022.
Citation F0804. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on November 1, 2022.
Citation F0809. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on November 1, 2022.
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 November 1, 2022.
Citation F0838. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on November 1, 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 November 1, 2022.
Citation F0561. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
CMS lists it as corrected on November 1, 2022.
Citation F0607. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS lists it as corrected on November 1, 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.
CMS lists it as corrected on November 1, 2022.
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 November 1, 2022.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on November 1, 2022.
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 November 1, 2022.
Citation F0697. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate pain management for a resident who requires such services.
CMS lists it as corrected on November 1, 2022.
6 citations
Fire safety inspection on September 30, 2022
CMS lists this as a standard inspection.
Citation K0321. Severity D: potential for more than minimal harm, isolated.
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 November 14, 2022.
Citation K0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on November 14, 2022.
Citation E0004. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Develop and maintain an Emergency Preparedness Program (EP).
CMS lists it as corrected on November 14, 2022.
Citation K0345. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on November 14, 2022.
Citation K0353. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on November 14, 2022.
Citation K0712. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on November 14, 2022.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- GENESIS WV HOLDINGS LLC5% or greater direct ownership interest · 100% · since 04/01/2011
- FC-GEN OPERATIONS INVESTMENT LLC5% or greater indirect ownership interest · no percentage provided · since 02/02/2015
- GEN OPERATIONS I LLC5% or greater indirect ownership interest · no percentage provided · since 02/02/2015
- GEN OPERATIONS II LLC5% or greater indirect ownership interest · no percentage provided · since 02/02/2015
- GENESIS HEALTHCARE INC5% or greater indirect ownership interest · no percentage provided · since 02/02/2015
- GENESIS HEALTHCARE LLC5% or greater indirect ownership interest · no percentage provided · since 02/02/2015
- GENESIS HOLDINGS LLC5% or greater indirect ownership interest · no percentage provided · since 02/02/2015
- GENESIS OPERATIONS LLC5% or greater indirect ownership interest · no percentage provided · since 02/02/2015
- GHC HOLDINGS LLC5% or greater indirect ownership interest · no percentage provided · since 02/02/2015
- SUN HEALTHCARE GROUP INC5% or greater indirect ownership interest · no percentage provided · since 02/02/2015
- WHITMAN, ARNOLD5% or greater indirect ownership interest · no percentage provided · since 02/02/2015
- ALBAUGH, MIRANDAOperational/managerial control · not applicable · since 05/01/2020
- BURNER, EILISHOperational/managerial control · not applicable · since 05/11/2020
Questions
When was Shenandoah Center last inspected?
CMS lists March 11, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Shenandoah Center have?
CMS lists 53 health citations since September 30, 2022. CMS also calls these deficiencies.
Has Shenandoah Center been fined?
CMS lists 4 fines in the past three years, $48,469 in total.
What is the CMS star rating of Shenandoah Center?
Its CMS overall star rating is 2 of 5.
Is Shenandoah Center a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.