Cycle 1
Health 2025-04-14 · Fire 2025-04-14
9 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Papillion, NE
Hillcrest Country Estates-Cottages
2-star overall rating with 2-star inspections with $13,000 in total fines with 9 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
6082 Grand Lodge Avenue, Papillion, NE
(402) 885-7000
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
48
Certified beds
Average residents
45
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2015-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.74
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
0.77
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
3.72
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
5.23
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
1.51
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
4.71
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.74
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.19
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.73
CMS adjusted RN staffing hours
Adjusted total hours
5.17
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
58%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,335
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.11
Composite VBP score used to determine payment impact.
Payment multiplier
1.0042
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.95
Baseline 17.83% · Performance 19.60% · Measure score 3.95 · Achievement 3.95 · Improvement 0
Healthcare-associated infections
5.73
Baseline 5.27% · Performance 6.12% · Measure score 5.73 · Achievement 5.73 · Improvement 0
Total nurse turnover
2.62
Baseline 87.10% · Performance 67.69% · Measure score 2.62 · Achievement 0 · Improvement 2.62
Adjusted total nurse staffing
7.75
Baseline 4.43 hours · Performance 5.28 hours · Measure score 7.75 · Achievement 7.75 · Improvement 5.79
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.88% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 408 · Observed rate 10.29% · Lower 95% interval 8.29% |
| Discharge to community | 66.5% |
50.57%
15.9 pts better
|
Better than the National Rate · Eligible stays 427 · Observed rate 61.83% · Lower 95% interval 61.42% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.43% |
95.27%
3.2 pts better
|
Numerator 250 · Denominator 254 |
| Falls with major injury | 1.57% |
0.77%
0.8 pts worse
|
Numerator 4 · Denominator 254 |
| Discharge self-care score | 69.31% |
53.69%
15.6 pts better
|
Numerator 140 · Denominator 202 |
| Discharge mobility score | 59.41% |
50.94%
8.5 pts better
|
Numerator 120 · Denominator 202 |
| Pressure ulcers or injuries, new or worsened | 3.94% |
2.29%
1.6 pts worse
|
Numerator 10 · Denominator 254 · Adjusted rate 5.17% |
| Healthcare-associated infections requiring hospitalization | 6.12% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 260 · Observed rate 5% · Lower 95% interval 4.28% |
| Staff COVID-19 vaccination coverage | 6.96% |
8.2%
1.2 pts worse
|
Numerator 8 · Denominator 115 |
| Staff flu vaccination coverage | 65.22% |
42%
23.2 pts better
|
Numerator 75 · Denominator 115 |
| Discharge function score | 62.38% |
56.45%
5.9 pts better
|
Numerator 126 · Denominator 202 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 69 · Denominator 69 |
| Transfer of health information to patient | 98.89% |
96.28%
2.6 pts better
|
Numerator 178 · Denominator 180 |
| Resident COVID-19 vaccinations up to date | 22.66% |
25.2%
2.5 pts worse
|
Numerator 29 · Denominator 128 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.6% |
92.8%
3.2 pts worse
|
93.4%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 79.2% · Q2 84.6% · Q3 96.0% · Q4 100.0% · 4Q avg 89.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.6% |
96.1%
3.5 pts worse
|
95.5%
2.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.2% |
4.5%
0.7 pts worse
|
3.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 3.8% · Q3 8.0% · Q4 4.8% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.4%
4.4 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 9.1% |
5.3%
3.8 pts worse
|
5.4%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 9.1% · 4Q avg 9.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.4% |
19.5%
13.1 pts better
|
19.6%
13.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 4.5% · 4Q avg 6.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.6% |
21.6%
2 pts better
|
16.7%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.3%
0.3 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 22.1% |
20.4%
1.7 pts worse
|
16.3%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.0% |
19.9%
6.9 pts better
|
14.9%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · 4Q avg 13.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
1.6%
0.9 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.9%
2.9 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 34.2% |
26.6%
7.6 pts worse
|
19.8%
14.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.7% · Q2 40.0% · Q3 22.1% · 4Q avg 34.2% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
4.3%
1.2 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.1% · Q3 3.7% · Q4 4.8% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 79.1% |
80.5%
1.4 pts worse
|
81.7%
2.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 62.0% · Q2 67.3% · Q3 86.9% · Q4 98.8% · 4Q avg 79.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.5% |
11.6%
3.1 pts better
|
12.0%
3.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.5% · Observed 8.0% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
2.4%
1.2 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 0.8% · Q4 3.4% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.7% |
75.9%
0.8 pts better
|
79.7%
3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.8% |
20.9%
0.1 pts better
|
23.9%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.8% · Observed 17.4% · Expected 19.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-29 · Fire 2024-02-29
8 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2023-03-21 · Fire 2023-03-21
5 health deficiencies
Top issue: Resident Rights (2 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-14
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-05-15
F · Potential for more than minimal harm
2025-04-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-15
F · Potential for more than minimal harm
2025-04-14
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-05-15
F · Potential for more than minimal harm
2025-04-14
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-05-15
F · Potential for more than minimal harm
2025-04-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-15
F · Potential for more than minimal harm
2025-04-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-15
F · Potential for more than minimal harm
2025-04-14
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-05-15
F · Potential for more than minimal harm
2025-04-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-15
F · Potential for more than minimal harm
2025-04-14
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-05-15
F · Potential for more than minimal harm
2024-02-29
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-04-10
F · Potential for more than minimal harm
2024-02-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-10
F · Potential for more than minimal harm
2024-02-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-10
F · Potential for more than minimal harm
2024-02-29
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-04-10
F · Potential for more than minimal harm
2024-02-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-10
F · Potential for more than minimal harm
2024-02-29
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-04-10
E · Potential for more than minimal harm
2024-02-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-04-10
F · Potential for more than minimal harm
2023-03-21
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-05-22
F · Potential for more than minimal harm
2023-03-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-22
F · Potential for more than minimal harm
2023-03-21
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-05-22
F · Potential for more than minimal harm
2023-03-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-22
F · Potential for more than minimal harm
2023-03-21
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-05-22
D · Potential for more than minimal harm
2023-03-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-22
D · Potential for more than minimal harm
2023-03-21
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-06-13
D · Potential for more than minimal harm
2023-03-21
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-05-22
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-04-14
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-05-15
E · Potential for more than minimal harm
2025-04-14
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2025-05-15
E · Potential for more than minimal harm
2025-04-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-05-15
E · Potential for more than minimal harm
2025-04-14
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-14
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-14
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-14
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-14
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-05-15
D · Potential for more than minimal harm
2024-04-24
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-05-30
D · Potential for more than minimal harm
2024-04-24
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-05-30
D · Potential for more than minimal harm
2024-04-24
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-05-30
D · Potential for more than minimal harm
2024-04-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-30
F · Potential for more than minimal harm
2024-02-29
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-10
E · Potential for more than minimal harm
2024-02-29
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-04-10
E · Potential for more than minimal harm
2024-02-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-10
D · Potential for more than minimal harm
2024-02-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-10
D · Potential for more than minimal harm
2023-11-13
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-06
F · Potential for more than minimal harm
2023-03-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-03
D · Potential for more than minimal harm
2023-03-21
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-05-03
D · Potential for more than minimal harm
2023-03-21
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2023-05-03
D · Potential for more than minimal harm
2023-03-21
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-05-03
Penalties and ownership
What sits behind the stars
$13,000
2023-03-21
Fine
Fine · fine $13,000
Fine
Ownership
Janicki, James
5% Or Greater Direct Ownership Interest · Individual
Mulhearn, Kevin
5% Or Greater Direct Ownership Interest · Individual
Oestmann, Matthew
5% Or Greater Direct Ownership Interest · Individual
Ripple, Reggie
5% Or Greater Direct Ownership Interest · Individual
Aswege-Mezenberg, Debra
Operational/Managerial Control · Individual
Hight, Kaleb
W-2 Managing Employee · Individual
Hillcrest Health Systems Inc
Operational/Managerial Control · Organization
Janicki, James
Operational/Managerial Control · Individual
Janicki, James
Corporate Officer · Individual
Mulhearn, Kevin
Operational/Managerial Control · Individual
Mulhearn, Kevin
Corporate Officer · Individual
Oestmann, Matthew
Operational/Managerial Control · Individual
Oestmann, Matthew
Corporate Officer · Individual
Ripple, Reggie
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Hillcrest Shadow Lake LLC
Papillion, NE
3-star overall rating with 2-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Brookestone of Papillion
Papillion, NE
5-star overall rating with 5-star inspections
#3
Hillcrest Health & Rehab
Bellevue, NE
2-star overall rating with 2-star inspections with 8 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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