Cycle 1
Health 2025-04-22 · Fire 2025-04-22
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Papillion, NE
Hillcrest Shadow Lake LLC
3-star overall rating with 2-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1507 E Gold Coast Road, Papillion, NE
(402) 339-6010
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
114
Certified beds
Average residents
105
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2016-09-23
CMS approved date
Coverage
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
0.33
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
0.39
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
2.73
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
3.45
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
0.72
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
3.24
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.21
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.37
CMS adjusted RN staffing hours
Adjusted total hours
3.80
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
64%
Annual nurse turnover · state 49% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data. |
| Medicare spending per beneficiary | Not Available |
1.02
|
This provider is not required to submit SNF QRP data. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · This provider is not required to submit SNF QRP data. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data. |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.8
0.5 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.4 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.0
0.6 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.5 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 70.9% |
92.8%
21.9 pts worse
|
93.4%
22.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 65.3% · Q2 69.1% · Q3 73.8% · Q4 74.8% · 4Q avg 70.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 87.5% |
96.1%
8.6 pts worse
|
95.5%
8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 87.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.1% |
4.5%
0.6 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.3% · Q3 4.9% · Q4 6.8% · 4Q avg 5.1% · 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% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 8.9% |
5.3%
3.6 pts worse
|
5.4%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 11.2% · Q3 7.6% · Q4 4.5% · 4Q avg 8.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.1% |
19.5%
2.6 pts worse
|
19.6%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 26.2% · Q3 21.7% · Q4 16.9% · 4Q avg 22.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.4% |
21.6%
2.2 pts better
|
16.7%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 19.0% · Q3 19.2% · Q4 20.0% · 4Q avg 19.4% · 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 | 7.8% |
20.4%
12.6 pts better
|
16.3%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 7.8% · Q3 3.1% · Q4 12.0% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.4% |
19.9%
13.5 pts better
|
14.9%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 6.4% · Q3 2.2% · Q4 12.9% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.6%
1.6 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
2.9%
1.4 pts better
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 2.9% · Q4 1.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.5% |
26.6%
4.9 pts worse
|
19.8%
11.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.5% · Q2 33.0% · Q3 34.8% · Q4 23.8% · 4Q avg 31.5% |
| Percentage of long-stay residents with pressure ulcers | 8.6% |
4.3%
4.3 pts worse
|
5.1%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 10.8% · Q3 7.8% · Q4 3.2% · 4Q avg 8.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 48.0% |
80.5%
32.5 pts worse
|
81.7%
33.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 45.5% · Q2 54.5% · Q3 37.0% · 4Q avg 48.0% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.5% |
2.4%
2.1 pts worse
|
1.6%
2.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 44.4% |
75.9%
31.5 pts worse
|
79.7%
35.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 44.4% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-04 · Fire 2024-04-04
14 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-02-14 · Fire 2023-02-14
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-22
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-04-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-04-22
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-06-03
F · Potential for more than minimal harm
2024-04-04
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-05-01
F · Potential for more than minimal harm
2024-04-04
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-05-01
E · Potential for more than minimal harm
2024-04-04
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-05-01
E · Potential for more than minimal harm
2024-04-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-01
E · Potential for more than minimal harm
2024-04-04
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2024-05-01
F · Potential for more than minimal harm
2023-02-14
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-05-11
F · Potential for more than minimal harm
2023-02-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-11
F · Potential for more than minimal harm
2023-02-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-11
E · Potential for more than minimal harm
2023-02-14
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-05-11
Inspection history
Recent health citations
G · Actual harm
2026-01-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Not marked corrected
D · Potential for more than minimal harm
2026-01-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Not marked corrected
D · Potential for more than minimal harm
2025-05-21
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-06-24
E · Potential for more than minimal harm
2025-04-22
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 2025-06-03
D · Potential for more than minimal harm
2025-04-22
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 2025-06-03
D · Potential for more than minimal harm
2025-04-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-03
D · Potential for more than minimal harm
2024-11-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-11-20
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 2025-01-02
G · Actual harm
2024-04-04
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 2024-05-01
F · Potential for more than minimal harm
2024-04-04
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 2024-05-01
F · Potential for more than minimal harm
2024-04-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-01
E · Potential for more than minimal harm
2024-04-04
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-05-01
E · Potential for more than minimal harm
2024-04-04
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-05-01
E · Potential for more than minimal harm
2024-04-04
F726 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2024-05-01
E · Potential for more than minimal harm
2024-04-04
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 2024-05-01
E · Potential for more than minimal harm
2024-04-04
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 2024-05-01
D · Potential for more than minimal harm
2024-04-04
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-04-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-04-04
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-04-04
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-05-01
F · Potential for more than minimal harm
2023-12-06
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-12-06
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 2024-01-17
D · Potential for more than minimal harm
2023-12-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-17
E · Potential for more than minimal harm
2023-02-14
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-03-29
E · Potential for more than minimal harm
2023-02-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-29
D · Potential for more than minimal harm
2023-02-14
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 2023-03-29
D · Potential for more than minimal harm
2023-02-14
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 2023-03-29
D · Potential for more than minimal harm
2023-02-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-29
D · Potential for more than minimal harm
2023-02-14
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 2023-03-29
D · Potential for more than minimal harm
2023-02-14
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-03-29
D · Potential for more than minimal harm
2023-02-14
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 2023-03-29
Penalties and ownership
What sits behind the stars
Ownership
Nearby options
Other facilities in reach
#1
Brookestone of Papillion
Papillion, NE
5-star overall rating with 5-star inspections
#2
Hillcrest Country Estates-Cottages
Papillion, NE
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
#3
Omaha Nursing and Rehabilitation Center
Omaha, NE
1-star overall rating with 1-star inspections with $154,118 in total fines with 21 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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