Shadow Hills Conv. Hospital
Inspection History Overview
Detailed Inspection Reports
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Fines and Penalties by Year
2021 2 penalties totaling $1,625
Fine
Fine
2020 2 penalties totaling $11,715
Fine
Fine
2019 1 penalties totaling $5,363
Fine
Health Violations by Year
2024 6 violations
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Ensure that residents are free from significant medication errors.
2023 14 violations
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Develop and implement 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 provides adequate supervision to prevent accidents.
Provide safe and appropriate respiratory care for a resident when needed.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 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.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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 rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Provide safe, appropriate pain management for a resident who requires such services.
2022 18 violations
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
PASARR screening for Mental disorders or Intellectual Disabilities
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide enough food/fluids to maintain a resident's health.
Post nurse staffing information every day.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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.
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.
Provide and implement an infection prevention and control program.
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Provide and implement an infection prevention and control program.
2021 7 violations
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Keep residents' personal and medical records private and confidential.
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.
Give the resident's representative the ability to exercise the resident's rights.
2020 30 violations
Provide and implement an infection prevention and control program.
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Reasonably accommodate the needs and preferences of each resident.
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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.
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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.
Provide activities to meet all resident's needs.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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 safe and appropriate respiratory care for a resident when needed.
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
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.
2019 12 violations
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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.
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Provide and implement an infection prevention and control program.
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
2018 12 violations
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure services provided by the nursing facility meet professional standards of quality.
Assist a resident in gaining access to vision and hearing services.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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.
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Provide and implement an infection prevention and control program.
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.