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Complaint Investigation

Gateway Vista

September 18, 2025 · Lincoln, NE · 225 North 56th Street
Citations 1
CMS Rating 3/5
Beds 80
Provider ID 285266
Healthcare Facility
Gateway Vista
Lincoln, NE  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

Gateway Vista in Lincoln, NE — inspection on September 18, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0697
Quality of Life and Care Deficiencies
Potential for More Than Minimal Harm

During an interview on 9/17/2025 at 3:45 PM with Licensed Practical Nurse (LPN) - B confirmed that Resident 1 came from the hospital with an order for Hydromorphone (Dilaudid) for five days and it was scheduled to be stopped during the weekend and when residents come with a stop date on pain meds, the facility will reassess their pain and address it from there. LPN-B further confirmed the facility did not have a plan for when Resident 1's five day scheduled order for Dilaudid was discontinued, and there was no plan to taper (gradually reduce) the medication.

Record review of Resident 1's Comprehensive Care Plan (CCP - written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) with a focus area dated 9/9/25, revealed the resident had chronic pain with a goal of adequate relief of pain, interventions included to identify previous pain history and management of that pain, administer analgesics, and document response.

During an interview on 9/18/25 at 1:37 PM with Director of Clinical Operations (DCO) confirmed there was no documentation of the resident pain assessment or condition between 12:20 PM and 2:35 PM for Resident 1 on 9/14/2025, the day of discharge.

The DCO also confirmed that pain is subjective (subjective means pain is described and reported based on the individual's perception and interpretation).

Record review of Resident 1's Minimum Data Set (MDS - this comprehensive assessment evaluates each resident's functional capabilities) dated 9/14/2025 revealed the resident discharged from the facility on 9/14/2025.

During an interview on 9/18/2025 at 3:43 PM with the Director of Nursing (DON) confirmed that Resident 1's pain was not under control, based on the pain assessment, when the resident was discharged .

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Lincoln, NE, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Gateway Vista or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.