Gateway Vista
Inspection Findings
F-Tag F0697
F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
not give the medication before the resident discharged from the facility. RN-A also confirmed that the facility had three Dilaudid 2 mg pills in the narcotic drawer for Resident 1. Record review of Resident 1's nurses notes dated 9/14/2025 at 2:35 PM revealed that resident's daughter removed Resident 1 from the facility against medical advice (AMA) because Resident 1 went 24 hours without Dilaudid (pain medication) and is taking them home to medicate (gender) and will not be returning to the facility. 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 .
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Gateway Vista in Lincoln, NE inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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.