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Hillcrest Shadow Lake LLC

1507 E Gold Coast Road, Papillion, NE 68046 · Sarpy County · (402) 339-6010

114 certified beds, about 95 residents a day · For profit - Limited Liability company · Medicaid since 2016

Certified for Medicaid
Overall
1 of 5
Health inspections
2 of 5
Staffing
1 of 5
Quality measures
4 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 28E299 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on April 22, 2025, inspectors cited 4 health deficiencies (the Nebraska average is 7.4, the national average 9.2).

Of 34 health citations since February 2023, 2 were rated as actual harm or immediate jeopardy to residents.

CMS lists no fines against this home in the last three years.

Nurses and nurse aides worked 3.51 hours per resident per day, against 3.98 across Nebraska and 3.86 nationally. Registered nurses accounted for 0.23 of those hours.

62.2% of nursing staff left within the year CMS measured (Nebraska average 48.7%).

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 34 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
21D
8E
3F
Potential for minimal harm
0A
0B
0C
May 7, 2026Complaint inspection · 1 citation
  1. D
    Provide enough food/fluids to maintain a resident's health.
    F692 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 17, 2026
    Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(J)(i)(1). Based on interview and record review the facility failed to identify and implement interventions for a significant weight loss for 1 (Resident 4) of 3 residents sampled. The facility census was 96.
January 20, 2026Complaint inspection · 3 citations
  1. G
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 16, 2026
    Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(iii)(1) & 12-006.09(H)(iii)(2). Based on observation, interview and record review the facility failed to evaluate, monitor, and implement interventions for pressure ulcer prevention and promotion of wound healing for 2 (Resident 1 and 3) of 4 residents sampled. The facility census was 95.
  2. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 16, 2026
    Inspectors wroteLicensure Reference Number 175 NAC 12-009.06 (H)(iii). Based on observation, interview and record review the facility failed to ensure vascular wounds were monitored to promote healing for 1 (Resident 2) of 1 residents sampled. The facility census was 95.
  3. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 20, 2026
    Inspectors wroteLicensure Reference Number 175 NAC 12-006.18(B)(D)Based on observation, interview, and record review the facility failed to ensure staff utilized infection control practices to prevent cross contamination of wounds during wound care for 2 of 2 residents sampled (Resident 1 and 2). The facility had a census of 44. A.A record review of the facility's Hand Hygiene Policy, dated 3/1/2022 revealed the following:Hand Hygiene GuidanceHealthcare personnel should use an alcohol-base hand rub or wash with soap and water for the following clinical indications:Before moving from work on a soiled body site to a clean body site on the same patient. [...]
May 21, 2025Complaint inspection · 1 citation
  1. D
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    F757 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 24, 2025
    Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H) Based on record review and interview, the facility failed to ensure that monitoring was in place for diuretic medication (a medication that increases the amount of urine produced by the kidneys and helps to remove excess fluid and salt from the body) administered to 3 of 6 residents surveyed (Residents 2, 3, and 4). The facility claimed a census of 109.
April 22, 2025Standard inspection, Complaint inspection · 4 citations
  1. E
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) June 3, 2025
    Inspectors wroteLicensure Reference Number 175 NAC 12.006.11(E) Nebraska 2017 Food Code 2-301.14 Nebraska Food Code 2017 3-302.11(4) Based on observations, record review and interview; the facility staff failed to utilize handwashing and gloving techneques during meal service and failed to serve foods in a manor to prevent potentail contamination. This had the potential to affect 44 residents. the facility census was 103.
  2. D
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 3, 2025
    Inspectors wroteLicensure Reference Number 175 NAC 12-006.02(H) Based on interview and record reviews; the facility failed to report an allegation of abuse to the required State Agency (SA) within the required timeframe for 1 (Resident 15) of 1 sampled resident. The facility staff identified a census of 103.
  3. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 3, 2025
    Inspectors wroteNebraska Licensure Reference Number 175 NAC 12-006.09(h)(vi)(3)(g) Based on interview and record review; the facility failed to measure and record pulse rates before and after a breathing treatment was administered for 1 (Resident 42) of 1 sampled resident. The facility staff identified a census of 103.
  4. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 3, 2025
    Inspectors wroteLicensure Reference Number 175 NAC 12.006.18 (D) Based on record review, observation and interview, the facility staff failed to perform hand hygiene before and after using gloves during medication administration for 2 (Residents 33 and 66) of 4 residents observed during medication pass. The facility census was 103.
November 20, 2024Complaint inspection · 2 citations
  1. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 2, 2025
    Inspectors wroteLicensure reference: 175 NAC 12-006.09(H) Based on observation, interview, and record review, the facility failed to ensure positioning to maintain body alignment for 1 [Resident 1] of 3 sampled residents. The facility had a total census of 103 residents.
  2. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 2, 2025
    Inspectors wroteLicensure reference: 175 NAC 12-006.09(l) Based observation, interview, and record review, the facility failed to ensure residents were transferred in accordance with plan of care for 2 [Residents 1 and 3] of 3 sampled residents. The facility had a total census of 103 residents.
April 4, 2024Standard inspection, Complaint inspection · 12 citations
  1. G
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 1, 2024
    Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D7a Based on interview and record review, the facility failed to ensure 1 (Resident 48) of 8 sampled resident's safety belt remain secured during the bathing process and implement interventions to prevent a fall with fracture for 1 (Resident 94) of 8 sampled residents. The facility census was 92.
  2. F
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) May 1, 2024
    Inspectors wroteLicensure Reference Number 175 NAC 12-006.11E Based on observation, interview, and record review, the facility failed to perform hand washing after touching potentially contaminated items during meal prep, place the blade in the puree blender in a sanitary manner, ensure staff did not touch the drinking surfaces of the cups of 12 residents in the E hall dining room to prevent cross-contamination. The facility failed to ensure the main kitchen and the Evergreen/Memory unit kitchen floors and equipment were cleaned and failed to ensure all items in the Evergreen/Memory Care unit refrigerator and freezer were labeled and dated to prevent the potential for food-borne illness. This had the potential to affect all 92 residents in the facility. The facility census was 92.
  3. F
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) May 1, 2024
    Inspectors wroteC. An observation on 04/03/2024 at 7:15 AM of Certified Medication Assistant K (CMA)-K performing blood glucose testing and insulin administration for Resident 74 revealed CMA-K gathered Resident 74's individual glucose monitor, a test strip, a cotton ball, a lancet and a pair of gloves. CMA-K also had 2 insulin flex pens, one of Lantus with 22 units of insulin and one of Humalog 5 units of insulin, both pens were prepared for administration with a safety needle attached. CMA-K entered the resident room and informed Resident 74 that CMA-K was there to test the residents blood glucose and administer insulin. Resident 74 agreed and CMA-K donned gloves without washing their hands or using hand sanitizer. CMA-K opened the alcohol wipe and wiped the forefinger on the right hand. [...]
  4. 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.
    F584 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 1, 2024
    Inspectors wroteLicensure Reference Number 175 NAC 12-006.18B3 Based on observations and interviews; the facility staff failed to ensure the venting system was functional in 4 (B-004, C-010, C-015 and C-017) room effecting 7 residents who resided in those rooms and failed to ensure the Heating and Cooling unit (commonly called PTAC) was maintained in good repair. This effected 7 of 92 residents. The facility staff identified a census of 92.
  5. E
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) May 1, 2024
    Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(9) Based on record review and interview; the facility staff failed to protect 4 (Resident 32, 92, 342 and 33) residents from abuse. The survey sample was 19 and the facility staff identified a census of 92.
  6. 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.
    F726 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) May 1, 2024
    Inspectors wroteLicensure Reference Number 175 NAC 12-006.04B2b Based on interview and record review, the facility staff failed to ensure competencies in insulin administration were completed for 5 Certified Medication Assistant (CMA) and 3 licensed nurses surveyed. This had the ability to affect 13 residents (Residents 6, 15, 19, 21, 25, 30, 38, 50, 60, 62, 74, 194 and 196) who receive insulin in the facility. The facility claimed a census of 92.
  7. 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.
    F758 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 1, 2024
    Inspectors wroteLicensure Reference Number 175 NAC 12-006.12B Based on record review and interview; the facility staff failed to have rationale for the continued use of an antianxiety medication for 3( Resident 1,21 and 25), failed to complete behavioral monitoring for 1(Resident 57) and failed to identify the need for a increase in dosage of a antidepressant medication for 1 (Resident) 1 of 5 residents sample size for the medication review. The facility staff identified a census of 92.
  8. 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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 1, 2024
    Inspectors wroteLicensure Reference Number 175 NAC 12-006.12E1 Licensure Reference Number 175 NAC 12-006.12E7 Based on observation and interview;the facility staff failed to ensure 2 medications in medication cart E were labeled for use, failed to ensure 2 medication carts and medications were secured and failed to ensure the medication refrigerator was secured in the memory care unit. This had the ability to affect 9 ambulatory residents of 22 residents who live on the memory care unit. The facility claimed a census of 92.
  9. D
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 1, 2024
    Inspectors wroteLicensure Reference Number 175 NAC 12-006.09C1c Based on observation, interview, and record review, the facility failed review and revise 1 (Resident 77) of 1 resident's Care Plan related to the oxygen order. The facility census was 92.
  10. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 1, 2024
    Inspectors wroteLicensure Reference Number 175 NAC 12-006.10D Based on observations, record review and interview; the facility staff failed to follow practitioners orders for medication administration for 1 (Resident 93) and failed to implement treatment orders for 1 ( Resident 25). The total survey sample was 19. The facility staff identified a census of 92.
  11. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 1, 2024
    Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D6(5) Based on observation, interview, and record review, the facility failed ensure the provider was notified when Resident 77's oxygen level dropped below the ordered parameter. The facility census was 92.
  12. D
    Provide care or services that was trauma informed and/or culturally competent.
    F699 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 1, 2024
    Inspectors wroteBased on record review, interview and observation, the facility staff failed to evaluate and implement interventions to manage triggers for 1(Resident 81) of 1 resident reviewed who has a diagnoses of Post Traumatic Stress Disorder (PTSD). The facility staff identified a census of 92.
December 6, 2023Complaint inspection · 3 citations
  1. F
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    F919 · Environmental · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · Corrected (the home has a date of correction) January 17, 2024
    Inspectors wroteLicensure Reference Number 175 NAC 12-006.04G Based on observations, record reviews and interviews, the facility failed to ensure staff had functional pagers that alerted staff when residents requested assistance (commonly known as call light). This had the potential to effect all residents in the facility. The facility staff identified a census of 105.
  2. D
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    F580 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 17, 2024
    Inspectors wroteLicensure Reference Number 175 NAC 12-006.04C3a(6) Based on record review and interview; the facility staff failed to notify the responsible party of the development of a pressure ulcer for 1(Resident 50) and failed to notify family of significant weight loss for 1 (Resident 4) of 4 sampled residents. The facility staff identified a census of 105.
  3. D
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 17, 2024
    Inspectors wroteLicensure Reference: 175 NAC 12-006.09D2a Based on record review and interview, the facility failed to ensure pressure sore treatment was initiated for 1 [Resident 4] of 4 sampled residents. The facility had a total census of 105 residents.
February 14, 2023Standard inspection · 8 citations
  1. 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.
    F584 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 29, 2023
    Inspectors wroteLicensure Reference Number 175 NAC 12-006.18 Based on observation and interview, the facility failed to maintain walls in good and cleanable condition in 15 (resident rooms A 1, A 2, A 7, A 9, B 3, B 4, B 5, B 11, C 6, C 7, E 4, E 5, E 6, E 7, E 10) of 56 occupied rooms. The facility census was 94.
  2. E
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 29, 2023
    Inspectors wroteLicensure Reference Number NAC 12-006.17B Based on observation, record review and interview the facility staff failed to ensure catheter cares were performed in a manner to prevent cross contamination for Res 45, failed to ensure Oxygen tubing was stored in a manner to prevent cross contamination for Res 16, and failed to ensure the cleaning and storage for nebulizer masks and tubing was completed to prevent cross contamination for Res 28, 32, and 62. The facility census was 94.
  3. D
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    F623 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 29, 2023
    Inspectors wroteBased on record review and interview, the facility failed to provide a written notice of transfer to the resident or representative for 4 hospitalizations for one of one sampled residents (Resident 62). The facility identified a census of 94.
  4. 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.
    F625 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 29, 2023
    Inspectors wroteBased on record review and interview, the facility failed to provide a signed bed-hold policy from the resident or representative related to 4 hospitalizations for one of one sampled residents (Resident 62). The facility identified a census of 94.
  5. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 29, 2023
    Inspectors wroteLICENSURE REFERENCE NUMBER 12-006.09D Based on record review and interview, the facility failed to follow physician's orders related to medications given outside of physician ordered parameters for 2 sampled residents (Resident 52 and Resident 62) and failed to prevent constipation for 1of 1 sampled residents (Resident 52). The facility census was 94.
  6. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 29, 2023
    Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.18 Based on observation, record review and interview; the facility staff failed to ensure fall interventions were implemented for Resident 19. The facility staff identified a census of 94.
  7. D
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    F698 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 29, 2023
    Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on record review and interview the facility staff failed to administer medications as ordered before dialysis for 1 (Resident 16) of 1 sampled resident. The facility staff identified a census of 94.
  8. 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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 29, 2023
    Inspectors wroteLicensure Reference Number 175 NAC 12-006.12E1 Based on observation, record review and interview the facility failed to ensure medications for 1 out of 6 residents sampled (Resident 16 ) were secured and stored safely. The facility census was 94 at the time of survey.

Fire safety inspections

12 fire safety citations on file: 3 on April 22, 2025, 5 on April 4, 2024, 4 on February 14, 2023.

Every fire safety citation12 citations
  1. 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.
    K 222 · April 22, 2025 · Corrected (the home has a date of correction)
  2. F
    Ensure proper usage of power strips and extension cords.
    K 920 · April 22, 2025 · Corrected (the home has a date of correction)
  3. F
    Ensure that testing and maintenance of electrical equipment is performed.
    K 921 · April 22, 2025 · Corrected (the home has a date of correction)
  4. F
    Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
    K 354 · April 4, 2024 · Corrected (the home has a date of correction)
  5. F
    Ensure that testing and maintenance of electrical equipment is performed.
    K 921 · April 4, 2024 · Corrected (the home has a date of correction)
  6. 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.
    K 222 · April 4, 2024 · Corrected (the home has a date of correction)
  7. E
    Install corridor and hallway doors that block smoke.
    K 363 · April 4, 2024 · Corrected (the home has a date of correction)
  8. E
    Meet requirements for the use and maintenance of medical gas equipment.
    K 922 · April 4, 2024 · Corrected (the home has a date of correction)
  9. F
    Implement emergency and standby power systems.
    E 41 · February 14, 2023 · Corrected (the home has a date of correction)
  10. F
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · February 14, 2023 · Corrected (the home has a date of correction)
  11. F
    Have generator or other power source capable of supplying service within 10 seconds.
    K 918 · February 14, 2023 · Corrected (the home has a date of correction)
  12. E
    Have proper medical gas storage and administration areas.
    K 923 · February 14, 2023 · Corrected (the home has a date of correction)

Fines and payment denials

CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

MeasureThis homeNebraskaUnited States
All nursing staff (RN, LPN and aides)3.513.983.86
Registered nurses0.230.670.69
All nursing staff on weekends3.223.483.42
Nurse aides2.70
Licensed practical nurses0.59
Nursing staff turnover (share who left in a year)62.2%48.7%45.8%
Registered nurse turnover63.6%44.1%42.9%
Administrators who left2

CMS expects 3.46 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.63 on weekdays and 3.22 on weekends, 11% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 21.7% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.31 in April to June 2025 to 3.51 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20263.510.233.633.22 21.7%0 of 9095
Oct to Dec 20253.390.253.483.18 14.2%1 of 92102
Jul to Sep 20253.450.333.533.24 10.2%0 of 92105
Apr to Jun 20253.310.453.423.04 19.5%0 of 91106
United States, Jan to Mar 20263.750.623.923.335.3%0.5% of days
Nebraska, Jan to Mar 20264.010.664.213.537.1%1.6% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

MeasureThis homeNebraskaUS
Percentage of long-stay residents whose need for help with daily activities has increased
Long Stay residents, 2025Q2-2026Q1
5.719.013.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
0.01.40.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
1.02.81.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
5.24.53.2
Percentage of short-stay residents who newly received an antipsychotic medication
Short Stay residents, 2025Q2-2026Q1
0.02.01.6
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
10.318.214.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
4.34.04.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
17.420.715.4
Number of hospitalizations per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
2.11.81.9
Number of outpatient emergency department visits per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
1.51.91.8

Owners and operators

Legal business name: Legal Business Name Not Available.

NameRoleTypeShareSince
Ownership data not available

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

  1. How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 14 problems in this area, most recently on May 7, 2026: "Provide enough food/fluids to maintain a resident's health."
  2. How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 5 problems in this area, most recently on April 4, 2024: "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."
  3. What changed in infection control since the last inspection, and who on staff is the infection preventionist?Inspectors cited 4 problems in this area, most recently on January 20, 2026: "Provide and implement an infection prevention and control program."
  4. How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 4 problems in this area, most recently on May 21, 2025: "Ensure each resident’s drug regimen must be free from unnecessary drugs."
  5. Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 3.22 hours per resident per day, below the Nebraska average of 3.48.
  6. How long has the current administrator been here?CMS counts 2 administrators who left in the period it measured.

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Common questions

What is Hillcrest Shadow Lake LLC's Medicare star rating?
CMS rates Hillcrest Shadow Lake LLC 1 out of 5 stars overall, with 2 for health inspections, 1 for staffing and 4 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did Hillcrest Shadow Lake LLC get at its last inspection?
4 health deficiencies at the standard inspection on April 22, 2025. The Nebraska average is 7.4.
Has Hillcrest Shadow Lake LLC been fined?
CMS lists no fines in the last three years.
Does Hillcrest Shadow Lake LLC accept Medicaid?
It is certified to take Medicaid (CMS lists it as "Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns Hillcrest Shadow Lake LLC?
CMS lists 1 owner or manager. Legal business name: Legal Business Name Not Available.

Sources

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