Hillcrest Shadow Lake LLC
1507 E Gold Coast Road · Papillion, NE · 68046 · 4023396010
114 certified beds For profit - Limited Liability company
- No federal fines or payment denials in CMS’s 3-year window.
- Inspection results have improved across recent cycles.
The composite number cleared 71 points, but Recommended is gated: inspection record below the Recommended bar. That rule is part of the published method.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
Cited under the freedom-from-abuse rule
Cited 1 time under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
RN staffing in the bottom 10% nationally
0.25 registered-nurse hours per resident per day, vs a 0.58 national median and 0.75 benchmark.
61% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 2 of 5 Staffing: 2 of 5 Quality measures: 4 of 5
| Total nurse hours / resident-day | 3.39 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.25 | 0.55–0.75 |
| Weekend hours / resident-day | 3.18 | ≈ weekday level |
| Nursing turnover / year | 61% | median 45% |
| Fines (3-yr window) | none |
Inspection citations (33 in the current record)
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Actual harm · G January 20, 2026 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected February 16, 2026 · Quality of Life and Care
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Potential for harm · D January 20, 2026 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected February 16, 2026 · Quality of Life and Care
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Potential for harm · D January 20, 2026 · found via complaint
Provide and implement an infection prevention and control program.
Corrected March 20, 2026 · Infection Control
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Potential for harm · D May 21, 2025 · found via complaint
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected June 24, 2025 · Pharmacy Service
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Potential for harm · D April 22, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected June 3, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D April 22, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Corrected June 3, 2025 · Quality of Life and Care
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Potential for harm · E April 22, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected June 3, 2025 · Nutrition and Dietary
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Potential for harm · D April 22, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected June 3, 2025 · Infection Control
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Potential for harm · D November 20, 2024 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected January 2, 2025 · Quality of Life and Care
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Potential for harm · D November 20, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected January 2, 2025 · Quality of Life and Care
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Actual harm · G April 4, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected May 1, 2024 · Quality of Life and Care
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Potential for harm · E 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.
Corrected May 1, 2024 · Resident Rights
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Potential for harm · D April 4, 2024
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected May 1, 2024 · Resident Assessment and Care Planning
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Potential for harm · D April 4, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected May 1, 2024 · Quality of Life and Care
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Potential for harm · D April 4, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Corrected May 1, 2024 · Quality of Life and Care
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Potential for harm · D April 4, 2024
Provide care or services that was trauma informed and/or culturally competent.
Corrected May 1, 2024 · Quality of Life and Care
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Potential for harm · E April 4, 2024
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 May 1, 2024 · Pharmacy Service
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Potential for harm · E April 4, 2024
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 May 1, 2024 · Pharmacy Service
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Potential for harm · F April 4, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected May 1, 2024 · Nutrition and Dietary
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Potential for harm · F April 4, 2024
Provide and implement an infection prevention and control program.
Corrected May 1, 2024 · Infection Control
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Potential for harm · E April 4, 2024 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected May 1, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E April 4, 2024 · found via complaint
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 May 1, 2024 · Nursing and Physician Services
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Potential for harm · D December 6, 2023 · found via complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected January 17, 2024 · Resident Rights
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Potential for harm · D December 6, 2023 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected January 17, 2024 · Quality of Life and Care
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Potential for harm · F December 6, 2023 · found via complaint
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected January 17, 2024 · Environmental
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 28E299 · certified since September 23, 2016. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.