Inspection Reports for Hillcrest Shadow Lake

NE, 68046

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Deficiencies (last 7 years)

Deficiencies (over 7 years) 5.9 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

40% worse than Nebraska average
Nebraska average: 4.2 deficiencies/year

Deficiencies per year

24 18 12 6 0
2016
2017
2018
2019
2023
2025
2026

Census

Latest occupancy rate 86% occupied

Based on a October 2018 inspection.

This facility has shown a steady increase in demand based on occupancy rates.

Census over time

81 90 99 108 117 126 Aug 2016 Aug 2017 Oct 2018
Notice Deficiencies: 0 Jan 20, 2026
Visit Reason
The document serves as a Notice of Disciplinary Action placing the facility's license on probation for 90 days starting February 17, 2026, due to failure to evaluate, monitor, and implement interventions for pressure ulcer prevention and wound healing.
Findings
The facility failed to comply with licensure regulations related to pressure ulcer prevention and promotion of wound healing, as evidenced by the CMS-2567 Report dated January 20, 2026.
Report Facts
Probation period: 90 Report due date: 27 Days to respond: 10 Days until disciplinary action final: 15
Employees Mentioned
NameTitleContext
Timothy TesmerChief Medical OfficerSigned the Notice of Disciplinary Action
Lisa OsborneAdministratorHealth Facilities Licensure Unit contact
Linda StenversAdministrative SpecialistCertified the Notice of Disciplinary Action mailing
Inspection Report Renewal Capacity: 114 Deficiencies: 0 Mar 28, 2025
Visit Reason
The document is a Nursing Home Licensure Renewal Application and renewal certification for Hillcrest Shadow Lake LLC, verifying that the nursing facility is licensed through the indicated renewal date.
Findings
The document certifies that Hillcrest Shadow Lake LLC meets statutory requirements for licensure as a nursing facility and includes ownership information, licensing fees, and special care and treatment services provided.
Report Facts
Number of beds to be relicensed: 114 Renewal license expiration date: 2025 Occupancy permit maximum beds: 115
Employees Mentioned
NameTitleContext
Matthew OestermannAuthorized RepresentativeSigned the Nursing Home Licensure Renewal Application on 3/28/2025
Reggie RippleAuthorized RepresentativeSigned the Nursing Home Licensure Renewal Application on 3/28/2025
Inspection Report Renewal Capacity: 114 Deficiencies: 0 Mar 11, 2023
Visit Reason
The document is a Nursing Home Licensure Renewal Application and related certification verifying that Hillcrest Shadow Lake LLC is licensed as a nursing facility through the renewal date.
Findings
The documents confirm that Hillcrest Shadow Lake LLC meets statutory requirements for licensure renewal as a nursing facility with no deficiencies or violations noted in the provided materials.
Report Facts
Total licensed beds: 114 Renewal application date: Mar 11, 2023
Employees Mentioned
NameTitleContext
Chris SobrilskyAdministratorNamed on the renewal application as facility administrator
Cara GunterDirector of NursingNamed on the renewal application as director of nursing
Inspection Report Complaint Investigation Deficiencies: 0 Jun 20, 2019
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging the facility failed to use appropriate interventions to prevent falls with injuries.
Findings
The facility was found to use appropriate interventions to prevent falls with injuries, with staff demonstrating knowledge and implementation of fall prevention measures. The facility was in compliance with relevant regulatory requirements.
Complaint Details
The complaint alleged failure to use appropriate interventions to prevent falls with injuries. The complaint was not substantiated as the facility was found compliant.
Employees Mentioned
NameTitleContext
Connie VogtProgram ManagerSigned as Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health
Inspection Report Annual Inspection Census: 99 Capacity: 115 Deficiencies: 6 Oct 11, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Hillcrest Shadow Lake from October 11 to October 17, 2018, by the Department of Health and Human Services Division of Public Health.
Findings
The facility was found to be in compliance with most regulatory requirements including protection from abuse, housekeeping, grooming, insulin monitoring, and respect for residents. However, the facility failed to consistently complete neurological checks after residents' falls with potential head injury, resulting in a citation. Additional deficiencies were found related to kitchen sanitation, life safety code violations including locking exit doors, hazardous area door closures, fire door inspections, and improper use of power strips and extension cords.
Complaint Details
The visit was complaint-related and included investigation of allegations such as failure to protect residents from abuse, housekeeping issues, grooming, misappropriation, and failure to follow care plans. Most allegations were found to be unsubstantiated except for failure to follow neurological check standards after falls.
Severity Breakdown
SS=D: 1 SS=F: 5
Deficiencies (6)
DescriptionSeverity
Failure to complete neurological assessments following falls with potential head injury for 3 residents.SS=D
Kitchen equipment was not maintained in a sanitary manner with dust, grease, and food particles present.SS=F
Locking device installed on an exit door which could delay egress during an emergency.SS=F
Failure to maintain hazardous area doors with self-closing devices and smoke-tight seals.SS=F
Lack of a complete preventative maintenance plan to inspect and test all fire doors annually.SS=F
Use of electrical extension cords and power strips as permanent wiring, creating fire hazard.SS=F
Report Facts
Facility census: 99 Total licensed capacity: 115 Residents reviewed for neurological assessments: 3 Number of residents affected by kitchen sanitation issue: 98 Number of beds: 115 Number of occupants affected by exit door locking device: 135
Employees Mentioned
NameTitleContext
Kevin SauberzweigAdministratorNamed as facility administrator in multiple documents
Dan TaylorRN, Training CoordinatorSigned complaint investigation letter
LPN-CLicensed Practical NurseInvolved in neurological assessment failure for Resident 256
NT-BNursing TechnicianReported change in responsiveness of Resident 256
Dain WeissRN, ReviewerConducted Informal Dispute Resolution
Becky WisellAdministrator, Licensure UnitSent notification of IDR decision
Connie VogtProgram Manager, Office of Long Term Care FacilitiesSent notification of IDR decision
Inspection Report Renewal Capacity: 115 Deficiencies: 0 Mar 21, 2018
Visit Reason
The document is a Nursing Home Licensure Renewal Application and verification for Hillcrest Shadow Lake, confirming the facility's license renewal and compliance with state requirements.
Findings
The documents confirm that Hillcrest Shadow Lake meets statutory requirements for licensure as a skilled nursing facility and includes verification of services offered and ownership information.
Report Facts
Total licensed beds: 115 License renewal fee: 1950
Employees Mentioned
NameTitleContext
Kevin SauberzweigAdministratorNamed as facility administrator on renewal application
Harmony WidmanDirector of NursingNamed as director of nursing on renewal application
Kris D'Ann MaplesIn-House Counsel/Compliance DirectorNamed as contact for compliance and licensing communications
Kevin MulhearnCFOMember of LLC ownership
Jolene RobertsOwner with more than 5% ownership interest
John RobertsOwner with more than 5% ownership interest
Inspection Report Complaint Investigation Deficiencies: 0 Oct 3, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging that the facility fails to put interventions into place to prevent injuries.
Findings
The facility was found to have ensured that appropriate interventions were being used to prevent injuries, with no violation related to the allegation. Incident reports, observations, and staff interviews confirmed proper interventions to prevent falls.
Complaint Details
The complaint alleging failure to implement interventions to prevent injuries was investigated and found to be unsubstantiated.
Employees Mentioned
NameTitleContext
Eve LewisProgram ManagerSigned the report and identified as Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS
Inspection Report Complaint Investigation Census: 102 Capacity: 115 Deficiencies: 21 Aug 7, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Hillcrest Shadow Lake from August 7, 2017 to August 14, 2017 by the Department of Health and Human Services Division of Public Health.
Findings
The facility was found to be out of compliance with federal regulations related to failure to report and investigate abuse allegations timely, failure to notify physicians of medication holds, failure to coordinate care plans with residents and families, failure to monitor pressure ulcers, and failure to ensure residents were free from significant medication errors. Several other areas were found in compliance including pest control, housekeeping, call system response, and abuse protection.
Complaint Details
The complaint investigation included allegations of misappropriation, resident protection from aggressive behaviors, timely submission of investigations, pest control, odor control, skin breakdown treatment, housekeeping, call system response, injury prevention, notification of changes, discharge coordination, fall prevention, activities, snack assistance, and abuse protection. The facility was found out of compliance for failure to report and investigate abuse allegations timely, failure to notify physicians of medication holds, failure to coordinate care plans with residents and families, failure to monitor pressure ulcers, and failure to ensure residents were free from significant medication errors.
Severity Breakdown
Level D: 3 Level G: 1
Deficiencies (21)
DescriptionSeverity
Failure to notify physician of medications held during dialysis for Resident 95.Level D
Failure to report and investigate potential abuse for Residents 70 and 130 within required timeframes.Level D
Failure to develop vision care plans for Residents 7 and 14 with documented vision loss.
Failure to include Resident 40 in care planning and failure to update care plans for Residents 104 and 7 related to eating preferences and urinary incontinence.
Failure to monitor pressure ulcers for Residents 111 and 118, including lack of measurements and staging.Level G
Failure to ensure Resident 95 received insulin as ordered by the physician.Level D
Failure to serve foods and beverages in a manner to prevent potential food borne illness, including improper handling of dishes and use of beard nets.
Failure to identify medication irregularities during pharmacist monthly review and failure to follow up on medication denial for Resident 32.
Failure to have an effective infection control program including failure to obtain culture and sensitivity testing, failure to evaluate gastrointestinal symptoms in multiple residents, and failure to perform hand hygiene during wound care.
Failure to provide full visual privacy in 6 semi-private rooms due to inadequate curtains.
Abrupt changes in elevation of walking surfaces in paths of egress exceeding 1/2 inch creating trip hazards.
Panic bar on Sunroom exit door required excessive force to release and required two devices to be released before door could open.
Failure to provide continuous illumination of exit discharge to public way and dining room lighting could be turned off.
Failure to provide smoke resistant enclosure for hazardous areas including generator room, medical storage, paint room, and wheelchair storage room.
Failure to train staff on handling grease fires, failure to ensure hood cleaning, and failure to ensure semi-annual hood exhaust inspection.
Fire alarm system circuit breaker not equipped with lock out device.
Failure to provide smoke resistant doors on corridor openings allowing smoke passage in multiple locations.
Failure to clean lint from inside commercial dryers near heating elements increasing fire risk.
Failure to inspect all portable fire extinguishers every 30 days and fire extinguishers obstructed by objects.
Failure to provide monthly testing of emergency generator at 30% load for 30 minutes and failure to document transfer time from normal to emergency power.
Failure to ensure fire alarm system activated within 24 hours of 3rd shift fire drills and failure to hold fire drills under varied conditions.
Report Facts
Deficiencies cited: 20 Resident census: 102 Total licensed capacity: 115 Medications not given: 15 Medications not given: 6 Medications not given: 14 Medications not given: 12 Medications not given: 18 Residents with UTI without culture and sensitivity testing: 9 Abrupt elevation changes: 3 Fire drills not held under varied conditions: 4 Fire drills conducted at same time: 5 Fire alarm panel lock out device: 0 Fire sprinkler dry system air leakage test: 0 Fire sprinkler heads corroded: 1 Fire sprinkler head clearance violations: 2 Fire sprinkler head gaps: 3 Fire sprinkler head missing escutcheon: 1 Fire sprinkler head lint covered: 1 Ceiling damage: 1 Fire extinguisher inspections: 0 Fire extinguisher obstructions: 3 Emergency generator monthly load test: 0 Emergency generator transfer time: No documentation of transfer time from normal to emergency power Egress door force to release panic bar: 18 Fire drills with fire alarm activation: 0
Employees Mentioned
NameTitleContext
Kevin SauberzweigAdministratorNamed as facility administrator in multiple documents
Eve LewisProgram Manager - Office of LTC Facilities - Licensure UnitSigned complaint investigation report and correspondence
Becky WisellAdministrator Licensure UnitSigned Notice of Disciplinary Action letter
Kimberly A. DivisRN, NSSCIIConducted Informal Dispute Resolution
Tracie R BallmerPerson Completing Form CMS-671Signed facility staffing form
Inspection Report Renewal Capacity: 115 Deficiencies: 0 Mar 20, 2017
Visit Reason
The document is related to the renewal of the nursing facility license for Hillcrest Shadow Lake, verifying that the facility meets statutory requirements and is licensed through the indicated renewal date.
Findings
The documents confirm that Hillcrest Shadow Lake is licensed as a Skilled Nursing Facility with a total licensed capacity of 115 beds. The renewal application includes ownership and accreditation information, and the facility holds an occupancy permit for 115 beds.
Report Facts
Total licensed beds: 115 Renewal fees: 1750
Employees Mentioned
NameTitleContext
Kevin SauberzweigAdministratorNamed in the Nursing Home Licensure Renewal Application
Harmony WidmanDirector of NursingNamed in the Nursing Home Licensure Renewal Application
Jolene RobertsPresident/CEOAuthorized representative signing the renewal application
John RobertsNamed as an owner with more than 5% ownership interest
Jolene RobertsNamed as an owner with more than 5% ownership interest
Inspection Report Complaint Investigation Deficiencies: 0 Feb 13, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint that the facility fails to protect residents from injuries related to ongoing falls.
Findings
The facility ensured that residents were protected from injury related to ongoing falls and found no violation related to this allegation after reviewing records, observations, and interviews.
Complaint Details
The complaint alleged failure to protect residents from injuries related to ongoing falls. The allegation was not substantiated as the facility properly assessed residents and developed appropriate care plans.
Employees Mentioned
NameTitleContext
Eve LewisProgram ManagerSigned the report as Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS
Notice Capacity: 115 Deficiencies: 0 Sep 23, 2016
Visit Reason
This letter serves as an amendment to the original letter regarding the bed certification change that occurred as a result of the change of ownership at Hillcrest Shadow Lake.
Findings
The facility converted all previous dually-certified 115 beds to Medicaid-only certified beds effective September 23, 2016.
Report Facts
Medicaid-certified beds: 115
Employees Mentioned
NameTitleContext
Danny VanourneyProgram Specialist, MDS/OASIS Automation CoordinatorAuthor of the amendment letter
Eve LewisProgram ManagerCC recipient of the letter
Inspection Report Complaint Investigation Deficiencies: 1 Sep 22, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint at Hillcrest Shadow Lake from September 22 to September 26, 2016, by representatives of the Department of Health and Human Services Division of Public Health.
Findings
The investigation found the facility was in compliance regarding abuse prevention, family inclusion in care planning, and accurate charting. The facility did fail to have enough low sugar desserts available for one meal but was working to accommodate residents' special dietary requirements and was not found in violation of regulatory requirements.
Complaint Details
The complaint allegations included failure to ensure residents are free from abuse, failure to include family in care planning, failure to ensure food provided follows diet orders, and failure to ensure charting is accurate and complete. The facility was found compliant with abuse, family involvement, and charting allegations, but had a deficiency related to food provision.
Deficiencies (1)
Description
Facility did fail to have enough low sugar desserts available for one meal observed.
Employees Mentioned
NameTitleContext
Eve LewisProgram ManagerSigned the report as Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS
Susan NewellAdministratorFacility Administrator addressed in the report
Inspection Report Annual Inspection Census: 92 Capacity: 115 Deficiencies: 13 Aug 29, 2016
Visit Reason
Annual Life Safety Code survey conducted to assess compliance with fire safety and building code regulations for Hillcrest Shadow Lake nursing facility.
Findings
The facility was found to have multiple deficiencies related to fire safety including blocked and improperly closing corridor doors, gaps in smoke separation doors, malfunctioning hazardous area doors, improper locking devices on egress doors, inadequate egress lighting, emergency lighting deficiencies, sprinkler head obstructions, use of corridors as air plenums, overdue kitchen hood hydrostatic testing, obstructed egress paths, improper storage of soiled linen carts, unsecured oxygen cylinders, and unsafe electrical wiring practices.
Severity Breakdown
SS=E: 8 SS=F: 5
Deficiencies (13)
DescriptionSeverity
Corridor doors blocked open or failing to close and latch properly.
Gaps greater than 1/8 inch in smoke separation doors.SS=E
Hazardous area doors failing to close and latch.SS=F
Use of more than one locking device on egress doors and delayed egress door issues.SS=E
Lack of illumination of exit discharge to public way.SS=E
Emergency lighting in dining rooms not providing required illumination.SS=E
Foreign matter on sprinkler head and inadequate clearance.SS=E
Corridors used as return air plenums, compromising protected egress.SS=F
Overdue hydrostatic test for kitchen hood suppression system.SS=F
Obstructions in means of egress corridors including resident bed, carts, and fans.SS=F
Soiled linen carts stored in corridors exceeding allowed capacity.SS=F
Unsecured and improperly segregated oxygen cylinders in storage room.SS=E
Use of extension cords and power strips beyond temporary installation and blocked electrical panel access.SS=E
Report Facts
Facility census: 92 Total licensed capacity: 115 Number of smoke compartments affected: 6 Residents affected by door deficiencies: 53 Residents affected by hazardous area door deficiencies: 92 Residents affected by locking device deficiencies: 35 Residents affected by egress lighting deficiencies: 35 Residents affected by emergency lighting deficiencies: 45 Soiled linen container capacity: 100 Oxygen cylinders unsecured: 4
Employees Mentioned
NameTitleContext
Maintenance Staff AConfirmed multiple fire safety deficiencies during interviews
Maintenance Staff BConfirmed multiple fire safety deficiencies during interviews
Staff CReported resident bed stored in corridor for several days
Tim IrwinVP of Facility Based OperationsSigned waiver request for Life Safety Code provisions
Don FritzAssistant State Fire MarshalApproved waiver request for Life Safety Code provisions
Notice Capacity: 115 Deficiencies: 0 APP2016
Visit Reason
The documents serve as official notices regarding the issuance and renewal of the nursing facility license for Hillcrest Shadow Lake, including a change of ownership and Medicaid number application.
Findings
The documents confirm the licensing status of Hillcrest Shadow Lake as a skilled nursing facility with a licensed capacity of 115 beds, detail the change of ownership from Huntington Park Care Center to Hillcrest Shadow Lake LLC effective July 1, 2016, and provide instructions for license display and renewal.
Report Facts
Total licensed beds: 115 License expiration date: Mar 31, 2017 License issuance date: Jul 1, 2016 Occupancy permit date: Apr 8, 2015
Employees Mentioned
NameTitleContext
Susan NewellAdministratorNamed as facility administrator on license application
Harmony WidmanDirector of NursingNamed as director of nursing on license application
Courtney N. PhillipsChief Executive OfficerSigned letter issuing license
Becky WisellAdministratorListed in licensure unit
Brendan L. BishopAuthorized RepresentativeSigned nursing home license application
Jolene RobertsAuthorized Representative / President/CEOSigned nursing home license application and letter regarding license transfer
Timothy J. IrwinVice President of Facility OperationsSigned letter regarding Medicaid number application
Linda JuckettePresident & CEOSigned letter regarding sale of Huntington Park Care Center to Hillcrest Shadow Lake
Notice Capacity: 115 Deficiencies: 0 APP2019
Visit Reason
This document serves to verify that Hillcrest Shadow Lake nursing facility is licensed through the indicated renewal date and includes the occupancy permit certifying maximum occupancy.
Findings
The facility is licensed as a nursing facility with a total licensed capacity of 115 beds. The Nebraska State Fire Marshal issued an occupancy permit confirming the maximum occupancy of 115 beds.
Report Facts
Licensed beds: 115
Employees Mentioned
NameTitleContext
Kevin SauberzweigAdministratorNamed in licensure renewal application
Harmony WidmanDirector of NursingNamed in licensure renewal application
Susen LindnerDeputy State Fire MarshalInspected and approved occupancy permit
Document Capacity: 114 Deficiencies: 0 APP2020
Visit Reason
This document package includes the renewal application for the nursing home license, verification of licensure status, ownership disclosure, and occupancy permits.
Findings
No inspection findings or deficiencies are reported in these documents; they primarily serve to confirm licensure renewal, ownership information, and occupancy capacity.
Report Facts
Total licensed skilled beds: 114 Occupant load: 115
Employees Mentioned
NameTitleContext
Kevin SauberzweigAdministratorNamed on the Nursing Home Licensure Renewal Application (page 2).
Harmony WidmanDirector of NursingNamed on the Nursing Home Licensure Renewal Application (page 2).
Sharyl RonanCEOSigned the Nursing Home Licensure Renewal Application and Ownership Disclosure (pages 2 and 4).
Kevin MulhearnCFOSigned the Nursing Home Licensure Renewal Application (page 2).
Notice Capacity: 115 Deficiencies: 0 APP2021
Visit Reason
The documents serve to verify licensure renewal for the nursing facility Hillcrest Shadow Lake and provide the occupancy permit issued by the Nebraska State Fire Marshal.
Findings
The documents confirm that Hillcrest Shadow Lake meets statutory requirements as a nursing facility and is licensed through the renewal date. The occupancy permit authorizes a maximum occupancy of 115 beds.
Report Facts
Licensed beds: 114 Maximum occupancy: 115
Notice Capacity: 114 Deficiencies: 0 APP2022
Visit Reason
This document serves to verify the license renewal for Hillcrest Shadow Lake LLC nursing facility and includes the renewal application and ownership disclosure forms.
Findings
The documents confirm that Hillcrest Shadow Lake LLC meets statutory requirements as a nursing facility and is licensed through 3/31/2023. The renewal application indicates 114 beds to be relicensed.
Report Facts
Total licensed beds: 114
Employees Mentioned
NameTitleContext
Chris SobrilskyAdministratorNamed in ownership and management information on renewal application
Kevin MulhearnCFONamed in ownership and management information on renewal application
Sharyl RonanCEONamed in ownership and management information on renewal application
Inspection Report Renewal Capacity: 114 Deficiencies: 0 APP2024
Visit Reason
This document serves as a renewal application and license verification for Hillcrest Shadow Lake LLC Nursing Facility, confirming licensure through the indicated renewal date.
Findings
The document certifies that Hillcrest Shadow Lake LLC meets statutory requirements as a nursing facility and includes licensing renewal details, ownership information, and occupancy permit data.
Report Facts
Total licensed beds: 114
Employees Mentioned
NameTitleContext
Barry EmersonAdministratorNamed in the renewal application as facility administrator
Sara ForsbergDirector of NursingNamed in the renewal application as director of nursing
Notice Deficiencies: 0 DAN081417
Visit Reason
The document serves as a Notice of Disciplinary Action against Hillcrest Shadow Lake nursing facility for violations including failure to assess and implement interventions to heal pressure sores, resulting in probation for 90 days starting September 12, 2017.
Findings
The facility was found in violation of multiple regulations including charge nurse requirements, administrator duties, medication errors, sanitary conditions, pharmacotherapy supervision, infection control, and privacy, specifically failing to assess and implement interventions for pressure sores.
Report Facts
Probation period length: 90 Date probation began: September 12, 2017 Date probation ended: Probation terminated as of January 3, 2018 Date of Notice of Disciplinary Action: August 28, 2017
Employees Mentioned
NameTitleContext
Eve LewisProgram ManagerContact for submission of required reports and responses
Thomas L. WilliamsChief Medical Officer, Director, Division of Public HealthSigned the Notice of Disciplinary Action
Becky WisellAdministrator, Licensure UnitMentioned in Notice of Disciplinary Action
Linda StenversStaff Assistant IICertified mailing of the Notice of Disciplinary Action
Dan TaylorRN, Training CoordinatorSigned letter terminating probation on January 3, 2018

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