Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Brookestone of Papillion
Papillion, NE · 110 certified beds · Last Life Safety survey February 20, 2025
CMS Certification Number 285268 · first certified May 2005
Ownership
Operated by VETTER SENIOR LIVING · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within NE
21 citations — more than 70% of the 180 certified nursing homes in NE. Compared within NE rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 0 citations; the earlier surveys in the window averaged 10.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (February 2026 to April 2026), and past the point by which nine in ten NE facilities have been surveyed. This facility’s last Life Safety survey was February 2025. Facilities in NE are typically surveyed 12–14 months after the last one (median 13), measured over 271 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
Get an email about Brookestone of Papillion
One email when it happens. No account; stop it any time with one click.
1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
1 of the 21 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 21 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in NE, and nationally. Surveyors differ markedly between states, so the NE figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 21 |
| Median facility in NE | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| November 8, 2022 | 15 |
| November 2, 2023 | 6 |
| February 20, 2025 | 0 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2023-11-02 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 2 | 2023-11-02 |
| K-0347 | Properly provide smoke detection systems in areas open to corridors. | 1 | 2023-11-02 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2022-11-08 |
| K-0919 | Meet requirements for the use of electrical equipment. | 1 | 2022-11-08 |
| K-0922 | Meet requirements for the use and maintenance of medical gas equipment. | 1 | 2022-11-08 |
| K-0712 | Have simulated fire drills held at unexpected times. | 1 | 2022-11-08 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2022-11-08 |
What the citations cover
- Smoke Deficiencies 8
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Egress Deficiencies 3
- Miscellaneous Deficiencies 3
- Other 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 8 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Egress Deficiencies | 3 |
| Miscellaneous Deficiencies | 3 |
| Construction Deficiencies | 1 |
| Emergency Preparedness Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
November 2, 2023 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (December 8, 2023) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (December 8, 2023) |
| K-0347 | Properly provide smoke detection systems in areas open to corridors. | Deficient, Provider has date of correction (December 8, 2023) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (December 8, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (December 8, 2023) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (December 8, 2023) |
November 8, 2022 — 15 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (December 5, 2022) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (December 5, 2022) |
| K-0222 | 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. | Deficient, Provider has date of correction (December 5, 2022) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (December 5, 2022) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (December 5, 2022) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (December 5, 2022) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (December 5, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (December 5, 2022) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (December 5, 2022) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (December 5, 2022) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (December 5, 2022) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (December 5, 2022) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (December 5, 2022) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (December 5, 2022) |
| K-0922 | Meet requirements for the use and maintenance of medical gas equipment. | Deficient, Provider has date of correction (December 5, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.