Federal inspection record · CMS data as of October 1, 2026
Hillcrest Shadow Lake LLC
1507 E Gold Coast Road, Papillion, NE · (402) 339-6010
- Certified beds
- 114
- Residents per day
- 96
- Ownership
- For-Profit
- Chain
- No chain reported
- Medicare / Medicaid
- Medicaid
- Certified since
- September 23, 2016
1
How this home got 2 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Nebraska.
-
Staffing
★★★★★−1 star
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★+1 star
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★2 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Nebraska homes
Hillcrest Shadow Lake LLC carries 75 inspection points. That is fewer than 26% of Nebraska's 178 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Nebraska: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–9 pts
- 4★ 9–31 pts
- 3★ 31–50 pts
- 2★ 50–94.25 pts
- 1★ over 94.25 pts
Bars show every rated home in Nebraska by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
34 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (2)
-
G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
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G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Everything else, by area of care
Quality of Life and Care12D
- D
Provide enough food/fluids to maintain a resident's health.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide care or services that was trauma informed and/or culturally competent.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Resident Rights5E
- E
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.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- E
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.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- D
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.
Infection Control4F
- D
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
- F
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
Pharmacy Service4E
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- E
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.
- E
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.
- D
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.
Nutrition and Dietary2F
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Freedom from Abuse, Neglect, and Exploitation2E
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- E
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Nursing and Physician Services1E
- E
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.
Resident Assessment and Care Planning1D
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Environmental1F
- F
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspection history
2025-04-22
8 health deficiencies · 3 fire-safety deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2024-04-04
15 health deficiencies · 5 fire-safety deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
2023-02-14
11 health deficiencies · 4 fire-safety deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 3 h 23 min of nursing staff time a day, 15 min of it from a registered nurse.
This home
3 h 23 min
Nebraska average
4 h 7 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 61% of nursing staff and 60% of registered nurses left in the past year, along with 2 administrators.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident daysAbout the same | 1.7 | 1.7 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.6 pts better | 1.3 | 1.9 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine29.1 pts worse | 63.9% | 93.0% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine1.8 pts worse | 93.8% | 95.6% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury0.4 pts worse | 4.9% | 4.5% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms4.4 pts better | 0.0% | 4.4% | 13.5% |
| Percentage of long-stay residents who lose too much weight0.1 pts better | 5.0% | 5.1% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication0.8 pts better | 18.2% | 19.0% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication3.1 pts better | 17.6% | 20.7% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.3 pts better | 0.0% | 0.3% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened5.7 pts better | 11.1% | 16.8% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased12.6 pts better | 6.4% | 19.0% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder1.3 pts better | 0.0% | 1.3% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection2.4 pts better | 0.3% | 2.7% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence3.4 pts worse | 28.4% | 25.0% | 18.3% |
| Percentage of long-stay residents with pressure ulcers1.4 pts better | 2.6% | 4.0% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine28.9 pts worse | 52.4% | 81.3% | 82.3% |
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Fire safety
12 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Gas, Vacuum, and Electrical Systems6F
- F
Ensure proper usage of power strips and extension cords.
- F
Ensure that testing and maintenance of electrical equipment is performed.
- F
Ensure that testing and maintenance of electrical equipment is performed.
- E
Meet requirements for the use and maintenance of medical gas equipment.
- F
Have generator or other power source capable of supplying service within 10 seconds.
- E
Have proper medical gas storage and administration areas.
Smoke3F
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
- E
Install corridor and hallway doors that block smoke.
- F
Inspect, test, and maintain automatic sprinkler systems.
Egress2F
- F
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.
- E
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.
Emergency Preparedness1F
- F
Implement emergency and standby power systems.
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Other homes nearby
-
Brookestone of Papillion
Papillion, NE · Vetter Senior Living
★★★★★- Worst citation, 3 yrs
- F
- Nursing / resident / day
- 4 h 24 min
- Fines
- $0
-
Hillcrest Country Estates-Cottages
Papillion, NE
★★★★★- Worst citation, 3 yrs
- F
- Nursing / resident / day
- 5 h 37 min
- Fines
- $0
-
Omaha Nursing and Rehabilitation Center
Omaha, NE · The Ensign Group
★★★★★- Worst citation, 3 yrs
- G
- Nursing / resident / day
- 3 h 33 min
- Fines
- $39,146