Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gateway Vista during CMS and state inspections, most recent first.
The facility did not notify the State Agency within the required five working days after a change in the DON, as confirmed by record review and administrator interview. This delay in notification had the potential to impact all residents in the facility.
A resident with chronic pain and a history of long-term opioid use experienced severe, uncontrolled pain after the facility failed to consistently assess, monitor, and revise pain management interventions. Despite repeated high pain ratings, documentation showed limited use of non-pharmacological interventions and no timely adjustment of the pain regimen after opioid therapy was discontinued. The resident ultimately left the facility against medical advice due to inadequate pain control.
Nonfunctional Bathroom Ventilation in Multiple Resident Rooms: Surveyors found bathroom vents not functioning in 15 resident rooms when tested with one ply tissue, including repeated observations in several rooms. Maintenance confirmed the issue during interview, and records showed monthly exhaust fan inspections were documented as functioning despite the observed ventilation failures.
Dirty PAP mask not cleaned or addressed in orders. A resident with COPD, OSA, dementia, and other chronic conditions used a PAP device nightly, but the care plan and orders did not include cleaning directions for the mask. Surveyors observed the mask on the nightstand on multiple occasions with scattered black and brown particles in it. An LPN confirmed the mask was dirty and did not know how often it should be washed or who was responsible, and the DCO confirmed the resident had no cleaning directions in the orders.
A resident with Parkinson's Disease, at high risk for falls, was injured due to staff failing to use a gait belt during a transfer, as required by the care plan. The resident fell, resulting in a pelvic fracture, highlighting a lapse in following assessed interventions for fall prevention.
A resident's MDS inaccurately indicated dialysis treatment, while the resident was actually undergoing plasmapheresis. The error was confirmed through interviews and record reviews, revealing a failure to ensure accurate resident assessments as required by federal regulations.
A resident admitted with multiple diagnoses, including a neck fracture, was ordered to wear a cervical collar when upright. Although observed wearing the collar, the facility failed to document this requirement in the Baseline Care Plan. The DON confirmed the omission.
A resident's care plan failed to document their Plasmapheresis treatment and AV fistula, despite these being critical aspects of their medical care. The omission was confirmed through interviews and record reviews, highlighting a deficiency in the facility's care planning process.
A resident with multiple medical conditions, including a surgical amputation, received wound care that did not adhere to infection control protocols. An RN failed to perform hand hygiene, used unsanitized scissors, and placed supplies on an unclean surface without a barrier. The facility's Infection Control Preventionist confirmed these actions violated the facility's policies.
Failure to Timely Notify State Agency of DON Change
Penalty
Summary
The facility failed to notify the State Agency within five working days following a change in the Director of Nursing (DON), as required by licensure regulations. Record review showed that the DON was changed on 9/13/25, but the notification form was not faxed to the Department of Health and Human Services (DHHS) until 9/29/25, exceeding the required timeframe. During an interview, the Administrator confirmed that the notification was not submitted within the mandated five working days. This deficiency had the potential to affect all 68 residents residing in the facility at the time.
Failure to Implement and Revise Pain Management Interventions
Penalty
Summary
A deficiency occurred when the facility failed to implement, monitor, and revise pain management interventions for a resident with chronic pain and a history of spinal surgeries. The resident was admitted with a diagnosis of chronic back pain and had been on long-term opioid therapy, specifically Dilaudid, prior to admission. Upon admission, the resident was prescribed Dilaudid 2 mg five times daily for five days, along with PRN acetaminophen. The facility's policy required ongoing assessment and revision of pain management based on the resident's needs and professional standards of practice. Throughout the resident's stay, documentation revealed inconsistent and inadequate assessment and management of pain. There were multiple instances where the resident reported severe pain (ratings of 7 to 10 on a 0-10 scale), yet there was no evidence that the pain management regimen was revised or that additional pharmacological or non-pharmacological interventions were implemented beyond rest. Documentation often lacked details regarding the site of pain, the effectiveness of interventions, and follow-up assessments. After the scheduled Dilaudid order ended, the resident experienced high pain levels, and the facility did not have a plan for tapering or continuing opioid therapy, nor did they ensure timely communication with the medical provider to obtain a new order. The resident ultimately went without Dilaudid for over 24 hours, leading to severe, uncontrolled pain. The family removed the resident from the facility against medical advice due to the lack of adequate pain control. Interviews with staff confirmed that there was no plan in place for managing the resident's pain after the Dilaudid order expired, and that follow-up with the provider was not completed in a timely manner. The DON confirmed that the resident's pain was not under control at the time of discharge.
Nonfunctional Bathroom Ventilation in Multiple Resident Rooms
Penalty
Summary
The facility failed to have functional bathroom ventilation in 15 resident rooms, including rooms 105, 110, 111, 112, 114, 201, 205, 206, 216, 218, 311, 312, 313, 318, and 413, out of 77 rooms surveyed. During the initial tour, surveyors observed that the bathroom vents in these rooms were not functioning when tested with one ply tissue. Additional observations later confirmed that bathroom vents in several rooms, including rooms 110, 111, 112, and 114, were still not functioning when tested again with one ply tissue. Maintenance confirmed during interview that the bathroom vents in those rooms were not functioning, and later stated there was an issue with the bathroom vents not functioning and that they were being worked on. Record review showed the facility had a ventilation system inspection process and monthly exhaust fan inspections documented as functioning.
Dirty PAP mask not cleaned or addressed in orders
Penalty
Summary
The facility failed to ensure that staff followed infection control and prevention principles related to cleaning respiratory equipment for one resident who used a PAP device. The resident had multiple diagnoses including Parkinson’s disease, COPD, heart disease, irregular heartbeat, high blood pressure, dementia, diabetes mellitus, and obstructive sleep apnea, and had a guardian. The resident’s MDS indicated use of a non-invasive mechanical ventilator during the last 14 days, and the order summary showed an order to wear a PAP device every evening and to have staff check every two hours to ensure the resident was wearing oxygen or the PAP mask. The resident’s care plan did not mention the PAP machine or cleaning the mask, and the facility’s noninvasive ventilation policy did not include directions for cleaning or storage of the machine or equipment, stating only that the facility would follow the manufacturer’s instructions. Survey observations found the PAP mask lying on the nightstand next to the machine on multiple occasions with scattered black and brown particles in it. The resident stated the PAP mask was worn every night. An LPN confirmed the mask was dirty, did not know how often it should be washed, and did not know who was responsible for washing it. The LPN also confirmed the resident could not independently put on or remove the mask, and there was no order for cleaning the mask in the resident’s orders. The DCO confirmed the PAP mask should be cleaned every time it was taken off and also confirmed the resident did not have directions for cleaning the PAP mask in the orders.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility staff failed to implement assessed interventions to prevent significant injury for a resident with Parkinson's Disease, who was at high risk for falls due to confusion, de-conditioning, and gait/balance problems. The resident's Comprehensive Care Plan (CCP) included interventions such as using a gait belt during transfers and ambulation, which were not followed. The resident required partial to moderate assistance with toilet transfers, as assessed by the Minimum Data Set (MDS), and had a history of falls, as noted in the Physical Therapy (PT) records. On the day of the incident, a Nursing Assistant (NA) was assisting the resident from the toilet without using a gait belt, contrary to the resident's care plan. As a result, the resident fell, and the NA fell with them, leading to the resident sustaining a left side superior Pubic Ramus fracture. The incident was documented in the facility's investigation report, which confirmed the failure to use the gait belt during the transfer, contributing to the resident's injury.
Inaccurate MDS Documentation for a Resident
Penalty
Summary
The facility failed to ensure the accuracy of a resident's Minimum Data Set (MDS), which is a comprehensive assessment of a resident's functional, medical, and mental status. Specifically, the MDS for a resident inaccurately indicated that the resident was on dialysis. However, upon review and interviews, it was confirmed that the resident was not on dialysis but was undergoing plasmapheresis, a different medical procedure. This discrepancy was identified through observations, interviews, and record reviews conducted by the surveyors. The resident in question had several medical diagnoses, including Chronic Inflammatory Demyelinating Polyneuritis, Anemia, Acute Kidney Failures, Multifocal Motor Neuropathy, and Thyrotoxicosis. Despite these conditions, the resident confirmed not being on dialysis and not having a dialysis catheter. The Director of Nursing and the MDS Coordinator also confirmed that the resident was not on dialysis, indicating an error in the MDS documentation. This inaccuracy in the resident's assessment was a violation of federal regulations requiring that assessments accurately reflect the resident's status.
Failure to Document Cervical Collar Use in Baseline Care Plan
Penalty
Summary
The facility staff failed to develop a Baseline Care Plan (BLC) for a resident within 48 hours of admission, as required. The resident, who was admitted with multiple diagnoses including hypertension, surgical amputation, falls, osteomyelitis, and a non-displaced type II dens fracture, was ordered by their practitioner to wear a cervical collar at all times when upright or mobilizing. An observation confirmed that the resident was seated upright in a wheelchair with the cervical collar in place. However, a review of the resident's BLC, initiated shortly after admission, revealed that the use of the cervical collar was not documented in the plan. The Director of Nursing confirmed this omission during an interview.
Care Plan Omission for Plasmapheresis and AV Fistula
Penalty
Summary
The facility failed to ensure that a resident's care plan included critical information about their medical treatments and conditions. Specifically, the care plan did not document that the resident was undergoing Plasmapheresis and had an arteriovenous (AV) fistula in the right arm. This omission was identified during a review of the resident's medical records, which showed that the resident had several medical diagnoses, including Chronic Inflammatory Demyelinating Polyneuritis and Acute Kidney Failure, and required Plasmapheresis every two weeks. Despite these significant medical needs, the care plan lacked any mention of the Plasmapheresis treatment or the presence of the AV fistula, which is essential for the procedure. Interviews with the resident, the Director of Nursing, and the MDS Coordinator confirmed the resident's ongoing Plasmapheresis treatment and the existence of the AV fistula. However, these critical details were not reflected in the care plan or the facility's daily duty sheet, which should have included special precautions related to the AV fistula. The oversight in updating the care plan with these essential medical details represents a deficiency in the facility's care planning process, as it failed to incorporate all necessary information to ensure the resident's well-being.
Infection Control Lapses During Wound Care
Penalty
Summary
The facility staff failed to adhere to proper infection prevention and control practices during wound care for Resident 109. The resident, who was admitted with diagnoses including hypertension, surgical amputation, osteomyelitis, and a non-displaced type II dens fracture, required a specific wound treatment on the right second amputated toe. During an observation, RN-C did not perform hand hygiene before or after glove use, placed treatment supplies on an unclean surface without a barrier, and used unsanitized scissors for the procedure. Additionally, RN-C did not change gloves or perform hand hygiene between different stages of the wound care process. The facility's Infection Control Preventionist confirmed that the observed practices did not comply with the facility's infection control policies. These policies require hand hygiene before and after glove use, the use of a clean barrier for wound supplies, and the sanitization of scissors before and after use. The failure to follow these protocols was acknowledged by RN-C during an interview, highlighting lapses in maintaining a sterile environment during wound care for Resident 109.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 107 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lincoln
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eastmont | 0.7 mi | ★★★★★ | 6 | 0 |
| Eventide Lincoln Care Center | 0.8 mi | ★★★★★ | 4 | 0 |
| St. Jane De Chantal | 1.7 mi | ★★★★★ | 27 | 0 |
| Holmes Lake Rehabilitation & Care Center | 1.9 mi | ★★★★★ | 10 | 0 |
| Ambassador Health Of Lincoln | 1.9 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Gateway Vista.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.