Shenandoah Center: Care Plan Failures - WV
Federal inspectors found that Resident #48's care plan contained no mention of the wandering, inappropriate eating habits, public urination, or exposure of private parts that both staff and other residents had witnessed and documented at the 75-bed facility.
The administrator told inspectors the facility had been trying to find "a more suitable place for resident #48 long term due to all his needs." Yet the care plan — the document that guides daily treatment decisions — remained dangerously incomplete.
RN #56 described the resident's difficult adjustment period to investigators. "The resident needed and still needs a lot of re-queuing and re-direction," the nurse said. "He took a few weeks to adjust to the new setting of being here and still comments about wanting to go home."
Despite staff observations and the resident's ongoing struggles, none of these critical behaviors appeared in his care plan. Federal regulations require facilities to develop complete care plans within seven days of assessment and keep them current as residents' conditions change.
The inspection revealed a systematic failure in care planning that could affect multiple residents beyond just #48. When staff don't document known behaviors like wandering into other rooms or using communal food sources inappropriately, they can't develop proper interventions to protect both the individual resident and others in the facility.
Resident #48's habit of drinking from other residents' cups and eating their food creates obvious infection control risks. His practice of getting ice from communal sources with bare hands compounds these dangers. Yet without these behaviors documented in his care plan, staff lack formal guidance on prevention strategies.
The wandering behavior poses additional safety concerns. When residents enter other people's rooms uninvited, it can cause distress to both parties and potentially lead to confrontations or falls. Proper care planning would typically include specific interventions like increased supervision, redirection techniques, or environmental modifications.
Public urination and exposure of private parts suggest the resident may need assistance with toileting schedules, continence management, or behavioral interventions. These issues require coordinated responses from nursing staff, but such coordination becomes impossible without proper documentation in the care plan.
The administrator's admission that they were seeking alternative placement for the resident suggests staff recognized the severity of his needs. However, this makes the care plan failures even more concerning — if the facility knew the resident required specialized care, why weren't his documented behaviors reflected in his treatment plan?
When inspectors presented Administrator #10 with evidence that the care plan failed to reflect witnessed and documented behaviors, she promised to "make sure they are correct going forward." This response came only after federal investigators discovered the deficiencies during their complaint investigation.
The timing raises questions about how long these care plan omissions had persisted. RN #56's comments suggest the resident's behavioral issues began shortly after admission and continued throughout his stay. If staff were providing "re-queuing and re-direction" without formal care plan guidance, other residents may have been exposed to unnecessary risks.
Care plans serve as the foundation for all nursing home services. They guide medication administration, therapy services, dietary needs, and safety precautions. When these documents remain incomplete or outdated, residents receive fragmented care that can lead to preventable complications.
The inspection found similar care planning deficiencies could affect other residents beyond #48. In a facility serving 75 people, systematic failures in care plan development and maintenance create risks throughout the building.
Federal investigators reviewed three resident records during their complaint investigation, finding care plan failures in one case. The inspection report notes this deficiency "has the ability to effect more then one resident," suggesting broader problems with the facility's care planning processes.
Resident #48 continues to comment about wanting to go home, according to nursing staff. Meanwhile, his documented behaviors remain unaddressed in the very document designed to ensure his safety and appropriate care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Shenandoah Center from 2025-11-06 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 4, 2026 · Our methodology
SHENANDOAH CENTER in CHARLES TOWN, WV was cited for violations during a health inspection on November 6, 2025.
RN #56 described the resident's difficult adjustment period to investigators.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.