Shadowbrook Post Acute
Inspection History Overview
Detailed Inspection Reports
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Fines and Penalties by Year
2021 1 penalties totaling $16,715
Fine
2018 1 penalties totaling $0
Payment Denial
Health Violations by Year
2025 9 violations
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Provide appropriate foot care.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide and implement an infection prevention and control program.
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Make sure that a working call system is available in each resident's bathroom and bathing area.
2024 31 violations
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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.
Keep residents' personal and medical records private and confidential.
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.
Make sure that a working call system is available in each resident's bathroom and bathing area.
Ensure each resident receives an accurate assessment.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Provide and implement an infection prevention and control program.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Assure that each resident’s assessment is updated at least once every 3 months.
Ensure each resident receives an accurate assessment.
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
2023 10 violations
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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.
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Provide safe, appropriate pain management for a resident who requires such services.
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Provide safe and appropriate respiratory care for a resident when needed.
Keep all essential equipment working safely.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
2022 4 violations
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Provide and implement an infection prevention and control program.
Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
2021 13 violations
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.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Ensure medication error rates are not 5 percent or greater.
Ensure that residents are free from significant medication errors.
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.
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
2020 1 violations
Provide and implement an infection prevention and control program.
2019 8 violations
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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.
Keep all essential equipment working safely.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Keep all essential equipment working safely.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
2018 25 violations
Reasonably accommodate the needs and preferences of each resident.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Respond appropriately to all alleged violations.
Provide safe, appropriate pain management for a resident who requires such services.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Give the resident's representative the ability to exercise the resident's rights.
Provide timely, quality laboratory services/tests to meet the needs of residents.
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Implement a program that monitors antibiotic use.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
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.
Ensure medication error rates are not 5 percent or greater.
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.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
2017 30 violations
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.
Listen to the resident groups and act on their complaints and suggestions that affect resident care and life.
Reasonably accommodate the needs and preferences of each resident.
Provide activities to meet the interests and needs of each resident.
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Ensure each resident receives an accurate assessment by a qualified health professional.
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
Ensure residents maintain acceptable nutritional status.
Give each resident enough fluids to keep them healthy and prevent dehydration.
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.
Ensure that residents are safe from serious medication errors.
Have enough nurses to care for every resident in a way that maximizes the resident's well being.
Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed.
Store, cook, and serve food in a safe and clean way.
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
Have a program that investigates, controls and keeps infection from spreading.
Provide bedrooms that hold no more than 4 residents per room.