Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hillcrest Country Estates-cottages during CMS and state inspections, most recent first.
Pharmacy recommendations from monthly drug regimen reviews were not completed in a timely manner for three residents, including those with dementia, depression, and multiple medication regimens. Despite repeated pharmacist notes and facility policy requiring follow-up within one week, recommendations such as reassessment of PRN medications and gradual dose reductions were not addressed for extended periods, as confirmed by DON interviews and record reviews.
Staff did not follow the RD-approved menu and recipes when preparing an Italian Tossed Salad, omitting required ingredients and altering the dish based on resident preferences without proper approval. This failure to adhere to established policies and recipes prevented confirmation of proper nutrition for residents in one cottage.
Surveyors found that the facility did not ensure proper cleanliness of food storage equipment, with a dried red substance left under ground beef in a freezer and standing water with food debris in a cooler where eggs and juice were stored. The Culinary Director confirmed the lack of cleaning schedules and improper food storage practices, in violation of facility policy.
A review of employee files revealed that several nurse aides did not receive required annual training in abuse prevention and dementia care, with documentation missing for both types of training in multiple cases. The facility's policy requires these annual in-services, but records did not show completion for the sampled staff.
Facility staff did not promptly notify the physician or responsible party when a resident with cognitive impairment and on anticoagulant therapy developed a large, painful bruise, nor did they ensure that abnormal lab results for another resident were reviewed by the provider. Staff interviews confirmed that required notifications were not made, in violation of facility policy.
A resident with cognitive impairment and on anticoagulant therapy was found with a large, unexplained bruise on the forehead. The facility did not submit the required investigation report to the state agency within five working days, and the DON confirmed there was no evidence of timely submission.
A resident with multiple complex medical conditions was admitted and did not have a baseline care plan developed within 24 hours as required by facility policy. The only care plan present was created several days after admission and addressed limited care areas, omitting required elements such as initial goals, ADL needs, and therapy plans.
The facility did not document or monitor specific behavioral symptoms to support the continued use of antidepressant medications for two residents with depression and dementia diagnoses. Both residents were receiving mirtazapine, but their medical records lacked evidence of behavioral monitoring, and the DON confirmed this omission during interviews.
Staff did not follow physician orders for respiratory equipment care, including failing to date nebulizer tubing and improperly storing a CPAP mask. Additionally, after a resident with cognitive impairment and on anticoagulants developed a head bruise, staff did not measure the injury, communicate with the practitioner, or initiate required neuro checks, delaying assessment and investigation.
The facility failed to maintain a medication error rate below 5%, resulting in a 9.8% error rate affecting four residents. Errors included administering medications without required vital sign checks, falsely documenting medication administration, and leaving medications at the bedside despite resident refusal.
The facility failed to follow the five rights of medication administration, resulting in significant medication errors for two residents. Both residents reported not receiving medications on time, causing severe pain and distress. The facility's management confirmed the errors and acknowledged that the medications were given outside of prescribed parameters. No medication error reports were found for the affected residents.
The facility failed to provide safe storage of drugs and biologicals, with medications found in unlocked cabinets and a scheduled II medication not stored under double lock. Additionally, a resident's eye drops were not in their original labeled container. Staff confirmed that these practices did not comply with the facility's policies.
The facility failed to perform proper hand hygiene during medication passes, affecting three residents. Observations revealed that a Medication Aide and an LPN did not adhere to the facility's 20-second handwashing policy and failed to wash hands after glove removal or before exiting residents' rooms. Both staff members were unaware of the correct hand hygiene procedures.
Failure to Complete Pharmacy Recommendations Following Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that pharmacy recommendations resulting from monthly drug regimen reviews were completed for three of five sampled residents. According to facility policy, a licensed pharmacist is required to conduct a medication regimen review for each resident, with any recommendations provided to the primary care provider and Director of Nursing (DON) for review and action prior to the next review. However, record reviews revealed that pharmacy recommendations for multiple residents were not addressed in a timely manner, as required by policy. For one resident with diagnoses including anxiety, mild dementia with mood disturbance, and depression, pharmacy notes indicated repeated requests for reassessment of PRN Lorazepam over several months, with no evidence that facility staff followed up on these recommendations. Another resident, who had moderate cognitive impairment and was receiving several medications including an antidepressant, had repeated pharmacy recommendations for a gradual dose reduction (GDR) of Escitalopram that were not addressed for nine months. A third resident with dementia, chronic kidney disease, depression, and hypertension also had pharmacy recommendations for GDR of psychotropic medications that were not acted upon for three months. Interviews with the DON confirmed that the expectation was for pharmacy recommendations to be completed within one week of receipt, but this was not done for the residents in question. The lack of timely follow-up on pharmacy recommendations was confirmed through both record review and staff interviews, indicating a failure to comply with facility policy and regulatory requirements regarding medication regimen review and follow-up.
Failure to Follow RD-Approved Menus and Recipes During Meal Preparation
Penalty
Summary
Facility staff failed to follow the approved menu and recipes for meal preparation in one of three cottages, specifically during the preparation of an Italian Tossed Salad. Observations revealed that the cook did not use the recipe approved by the Registered Dietitian (RD) and omitted required ingredients such as red onion and parmesan cheese, instead only including lettuce and cucumber. The cook stated that menus were hardly ever used and that kitchen staff altered the salad based on resident preferences without following the proper process for menu changes. The Culinary Director (CD) and RD both confirmed that not following the RD-approved recipes prevents confirmation of proper nutrition and alters the nutritional value of the dish. The deficiency was identified through record reviews, staff interviews, and direct observation, affecting one cottage with 13 residents receiving food from that kitchen. The RD was unaware that recipes were not being followed and confirmed that any menu changes should be approved through the RD. The facility's policy requires that all food items be prepared using methods and recipes that conserve nutritional value and support the current menu, but this was not adhered to during the observed meal preparation.
Failure to Maintain Cleanliness of Food Storage Equipment
Penalty
Summary
The facility failed to maintain the cleanliness of food storage equipment in two separate kitchen areas, as observed during surveyor walkthroughs. In Cottage 80, a dried red substance was found beneath a roll of ground beef on the bottom shelf of a reach-in freezer, with no barrier in place. This condition persisted over multiple days, as confirmed by both observation and interview with the Culinary Director (CD). The CD acknowledged the issue and revealed that the facility had been without a CD for an extended period prior to their arrival, resulting in the absence of cleaning schedules in the culinary department. In the Rehab Cottage, a reach-in cooler was found to contain standing water with floating food debris on the bottom shelf. Initially, no food items were stored on this shelf, but later observations showed a cardboard box of eggs and a box of juice cartons placed directly in the standing water. The CD confirmed the presence of the standing water and the improper storage of food items. These findings were in direct violation of the facility's own Culinary Cleaning Policy, which requires thorough cleaning and sanitation of equipment and surfaces, as well as the use of cleaning checklists and regular audits.
Failure to Provide Annual Abuse and Dementia Training to Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides received required annual training in abuse prevention and dementia care, as evidenced by a review of five employee files. Each file reviewed, including those for nurse aides hired as early as June 2022 and as recently as April 2024, lacked documentation of completed annual abuse and dementia training. Specifically, none of the five nurse aides had documentation of annual dementia training, and two did not have documentation of annual abuse training. An interview with the Regional Nurse Consultant confirmed the absence of these required trainings for the identified nurse aides. The facility's own policy mandates annual in-services for all team members, including abuse and neglect and dementia behavior management, but the records reviewed did not show compliance with this policy for the sampled staff.
Failure to Notify Physician and Responsible Party of Change in Condition and Abnormal Lab Results
Penalty
Summary
Facility staff failed to promptly notify the attending physician and the resident's responsible party of a significant change in condition for a resident with cognitive impairment and multiple care needs. The resident, who had short and long-term memory problems, moderately impaired decision-making skills, and required extensive assistance with daily activities, was found to have a large, painful bruise on the forehead during a skin evaluation. Despite the resident being on anticoagulant medication, which increases the risk of complications from bruising, there was no documentation of communication with the physician or responsible party from the time the bruise was first identified until it was later noticed by the resident's daughter. Additionally, the facility failed to ensure that abnormal laboratory results for another resident with moderately impaired cognition and multiple chronic conditions were reviewed by the provider. The laboratory results included several abnormal findings, such as low red blood count, hemoglobin, hematocrit, and eGFR, as well as elevated glucose and hemoglobin A1c levels. There was no confirmation that these results were communicated to or reviewed by the provider as required by facility policy. Interviews with facility staff, including the Clinical Care Coordinator and Director of Nursing, confirmed that the required notifications to the physician and responsible party were not made in both cases. Facility policies clearly state the need for prompt notification of changes in condition, injuries, and abnormal laboratory results, but these procedures were not followed, resulting in deficiencies related to communication and timely notification.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to submit an investigation report to the state agency within five working days regarding an injury of unknown origin for one resident. The resident in question had short and long-term memory problems, moderately impaired decision-making skills, and required varying levels of assistance with daily activities. The resident was also on anticoagulant medication. On a specified date, staff identified a large bruise on the resident's forehead during a skin evaluation, with the cause of the injury unknown and unobserved by staff. Record review showed that the facility's investigation determined the bruise was of unknown origin, meeting the criteria for an injury of unknown source as outlined in the facility's policy. Despite this, there was no confirmation that the required investigation report was submitted to the state agency within the mandated timeframe. The DON confirmed that such a report should have been sent and that there was no evidence of submission via email or fax.
Failure to Complete Baseline Care Plan Within 24 Hours of Admission
Penalty
Summary
The facility failed to complete a baseline care plan within 24 hours of admission for a resident who was admitted with multiple complex medical conditions, including unspecified encephalopathy, paroxysmal atrial fibrillation, an implantable cardiac defibrillator, essential hypertension, a history of transient ischemic attack, cerebral infarction without residual deficits, hemiplegia and hemiparesis affecting the right dominant side, dysphagia, and difficulty walking. The resident was a full code and required assistance from one person to ambulate with a walker. Upon review, the only care plan present was dated several days after admission and addressed only two care areas: risk for falls and risk of impaired nutritional status. Further review of the facility's Baseline Care Plan Policy revealed that a baseline plan of care should be developed within 24 hours of admission and must include specific elements such as initial goals for care, immediate ADL needs, initial orders, dietary orders, therapy plan, social services, and PASRR recommendations if applicable. An interview with the Regional Consultant confirmed that the baseline care plan was not developed within the required timeframe for this resident.
Failure to Monitor Behavioral Symptoms for Antidepressant Use
Penalty
Summary
The facility failed to identify and monitor specific behavioral symptoms to justify the continued use of antidepressant medications for two residents. For one resident with diagnoses including anxiety, mild dementia with mood disturbance, and depression, the medical record showed ongoing administration of mirtazapine for depression, but there was no documentation of monitoring for specific behavioral symptoms related to the medication's use. The resident's Minimum Data Set (MDS) indicated receipt of antipsychotic, antianxiety, and antidepressant medications, as well as wandering behavior, but no behavioral monitoring was recorded in the electronic medical record. Similarly, another resident with diagnoses of dementia without behavioral disturbance, chronic kidney disease, depression, and hypertension was also receiving mirtazapine for depression. The MDS for this resident indicated no behavioral symptoms, and the medical record lacked documentation of monitoring for specific behavioral symptoms to support the continued use of the antidepressant. Interviews with the Director of Nursing confirmed that the facility did not identify or monitor specific behavioral symptoms for either resident, contrary to facility policy and expectations.
Failure to Follow Physician Orders and Post-Injury Monitoring Protocols
Penalty
Summary
The facility failed to follow physician orders and established protocols for the care and treatment of residents using respiratory equipment and for monitoring after a head injury. For one resident, staff did not change or date nebulizer tubing and masks as ordered, nor did they store the CPAP mask in a clean, dry area or use a respiratory setup bag when not in use. Multiple observations showed the nebulizer tubing was undated and the CPAP mask was improperly stored, with staff interviews confirming these lapses. Additionally, another resident with significant cognitive and physical impairments, who was on anticoagulant therapy, developed a large bruise on the forehead. Staff did not measure the bruise, communicate with the practitioner or responsible party, or initiate neurological checks as required by facility policy after a head injury. The etiology of the bruise was not investigated in a timely manner, and documentation of the injury and related assessments was delayed.
Medication Administration Errors and Documentation Issues
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 9.8% error rate affecting four residents. For Resident 9, the medication aide administered Carvedilol without taking the required blood pressure or heart rate, despite the order specifying parameters for administration. The last recorded vital signs were from three days prior, and the Director of Nursing confirmed that the parameters were still in effect and should have been followed. Resident 7 was given a chewable tablet that was left at the bedside despite the resident's refusal to take it. The medication aide documented that the medication was ingested, which was later found to be false as the tablet remained untouched. The aide admitted to documenting the medication as taken without witnessing its consumption. Similarly, Resident 8 was given Metoprolol without the required blood pressure or pulse check, and Diclofenac gel was documented as applied when it was not. The medication aide later admitted to forgetting to check the vital signs and falsely documenting the application of the gel. Resident 2 was given scheduled medications, but the application of Betadine to a wound on the right great toe was documented without being performed. The Licensed Practical Nurse admitted to planning to do the treatment later but had already documented it as completed. The Director of Nursing confirmed that medications and treatments should not be documented until they are actually administered or completed. The facility's policies and competency checklists were reviewed, highlighting the requirements for proper medication administration and documentation, which were not followed in these instances.
Significant Medication Errors Due to Failure to Follow Administration Protocols
Penalty
Summary
The facility failed to follow the five rights of medication administration, resulting in significant medication errors for two residents. Resident 2, who has multiple diagnoses including multiple sclerosis, asthma, hypertension, and muscle weakness, reported not receiving medications on time, including pain medication, on several occasions. Specific instances in March 2024 were documented where medications were either given late or not at all, causing severe pain and distress to the resident. The resident's Medication Administration Record (MAR) showed multiple instances of late administration and missing documentation for medications that were supposed to be given at specific times. Resident 9, who has diagnoses of congestive heart failure, hypertension, edema, and macular degeneration, also reported not receiving medications timely. The resident's MAR for March 2024 revealed several instances where medications were administered hours late, causing distress and sleeplessness. There were also instances where medications were not documented as given at all. Both residents had no progress notes in their electronic health records related to the late administration or missed medications, and there was no documentation of updates to their medical doctors. An interview with the facility's management team, including the Assistant Administrator, Director of Nursing (DON), Clinical Coordinator, and other staff, revealed that no one in management reviews the MARs or Treatment Administration Records (TARs) for completeness and timeliness. The DON confirmed that the medications were given outside of the prescribed parameters and acknowledged that these were medication errors. The facility's policies on medication administration and error reporting were not followed, as there were no medication error reports for the affected residents in the facility's incident log.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to provide safe storage of drugs and biologicals, as observed during a survey. Medications were found in unlocked cabinets in rooms occupied by residents in Cottage 70. Specifically, an unlocked medication cabinet was observed during a morning medication pass, and further investigation revealed another unlocked cabinet in a different room. Interviews with a Medication Aide (MA) and a Licensed Practical Nurse (LPN) confirmed that the cabinets should be locked at all times, and a maintenance order was to be completed to fix the cabinet that would not lock. Additionally, a scheduled II medication was found in an unlabeled medication cup in a resident's cabinet, which was not in its original container and not under double lock as required. The LPN admitted to placing the medication in the cabinet earlier in the day, following instructions from a day nurse, but could not recall the exact time it was done. The narcotic count sheet confirmed the medication was pulled from a locked box at 6:00 PM, but it was not stored properly afterward. Furthermore, an observation revealed that a resident's eye drops were not in their original labeled container. The eye drops were found in a small open plastic package with a small label, but the package had no date. The MA confirmed that the eye drops should be in the original box with a label containing the resident's name and directions. Interviews with the Director of Nursing (DON) and other staff confirmed that all medication cabinets should be locked and medications should be kept in their original packages with labels. The facility's policies on medication administration and storage were reviewed, highlighting the requirements for safe and secure storage of medications, which were not followed in these instances.
Failure to Perform Proper Hand Hygiene During Medication Pass
Penalty
Summary
The facility failed to perform proper hand hygiene during morning and evening medication passes, which had the potential to affect three out of six sampled residents. Observations revealed that a Medication Aide (MA-C) did not perform hand hygiene after glove removal or upon exiting residents' rooms. Specifically, MA-C washed hands for only 10 seconds instead of the required 20 seconds and did not wash hands after removing gloves or before leaving the room. This was confirmed during an interview with MA-C, who was unaware of the facility's hand hygiene policy. The Director of Nursing (DON) confirmed that the facility policy requires 20 seconds of handwashing and that hand hygiene should be performed after glove removal and before exiting the resident's room. Additionally, during the evening medication pass, a Licensed Practical Nurse (LPN-D) also failed to adhere to the facility's hand hygiene policy. LPN-D washed hands for only 10 seconds at the kitchen sink and was unaware of the required 20-second handwashing policy. The facility's undated Handwashing Competency Checklist specifies that handwashing should be performed for at least 20 seconds and lists multiple instances when hand hygiene is necessary, including after glove removal and before and after elder contact.
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Illustrative
What surveyors actually found near you
We read the 413 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Papillion
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hillcrest Shadow Lake Llc | 1.7 mi | ★★★★★ | 4 | 0 |
| Brookestone Of Papillion | 2.4 mi | ★★★★★ | 0 | 0 |
| Hillcrest Health & Rehab | 4.6 mi | ★★★★★ | 5 | 0 |
| Omaha Nursing And Rehabilitation Center | 4.8 mi | ★★★★★ | 3 | 0 |
| Emerald Nursing & Rehab Omaha | 5.9 mi | ★★★★★ | 31 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.