HILLCREST SHADOW LAKE

Nursing Home Inspector

1507 E GOLD COAST ROAD
PAPILLION, NE 68046
Sarpy County
Phone: 402-339-6010
Provider Number: 28E299
Last Inspection: 08/14/2017

About the Nursing Home

Number of Beds: 115
Number of Residents: 103
Beds Available: 12
Percent Occupancy: 90%
Insurance Accepted: Medicaid
Types of Councils: Resident
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

36

Facility
26

County
20

NE
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

36

2017
0

2016

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

8/14/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 9/12/2017
 
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 9/12/2017
 
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 9/12/2017
 
Failed To: Provide bedrooms that don't allow residents to see each other when privacy is needed. Pattern : Minimal 4 9/12/2017
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Widespread : Minimal 5 9/12/2017
 
Failed To: At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Isolated : Minimal 3 9/12/2017
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 9/12/2017
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Actual 4 9/12/2017
 
Failed To: Ensure that residents are safe from serious medication errors. Isolated : Minimal 3 9/12/2017
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 9/12/2017
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

No Complaint Deficiencies Reported

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg NE State Avg
Number of Residents 103 70.20 53.60
Registered Nurses 0.45 0.72 0.76
Licensed Practical / Vocational Nurses 0.68 0.69 0.68
Certified Nursing Assistants 2.00 2.19 2.49
Total Staff Hours 3.12 3.60 3.93

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% NE State Avg%
of high risk long-stay residents with pressure ulcers 6 3 4
of long-stay residents assessed and appropriately given the pneumococcal vaccine 99 93 94
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 100 96 96
of long-stay residents experiencing one or more falls with major injury 7 4 4
of long-stay residents who have depressive symptoms 14 5 5
of long-stay residents who lose too much weight 9 9 7
of long-stay residents who received an antianxiety or hypnotic medication 18 18 21
of long-stay residents who received an antipsychotic medication 21 14 18
of long-stay residents who self-report moderate to severe pain 1 4 9
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 25 24 19
of long-stay residents whose need for help with daily activities has increased 30 19 15
of long-stay residents with a catheter inserted and left in their bladder 4 3 2
of long-stay residents with a urinary tract infection 8 5 5
of low risk long-stay residents who lose control of their bowels or bladder 58 59 46
of short-stay residents assessed and appropriately given the pneumococcal vaccine 98 91 83
of short-stay residents who made improvements in function 76 7 8
of short-stay residents who newly received an antipsychotic medication 2 68 75
of short-stay residents who self-report moderate to severe pain 6 1 2
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 92 13 19
of short-stay residents with pressure ulcers that are new or worsened 0 90 80