Cycle 1
Health 2025-09-03 · Fire 2025-09-03
4 health deficiencies
Top issue: Administration (1 deficiency)
16 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Lincoln, NE
Gateway Vista
3-star overall rating with 3-star inspections with $8,659 in total fines with 4 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
225 North 56th Street, Lincoln, NE
(402) 464-6371
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
75
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2005-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.86
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
1.48
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
2.35
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
4.69
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
2.34
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
4.03
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.57
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.87
CMS adjusted RN staffing hours
Adjusted total hours
4.75
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
67%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,124
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.77
Composite VBP score used to determine payment impact.
Payment multiplier
0.9813
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.52% · Performance 22.29% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.03
Baseline 4.70% · Performance 7.53% · Measure score 1.03 · Achievement 1.03 · Improvement 0
Total nurse turnover
0
Baseline 61.17% · Performance 62.39% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
4.48
Baseline 4.38 hours · Performance 4.35 hours · Measure score 4.48 · Achievement 4.48 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.21% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 479 · Observed rate 9.6% · Lower 95% interval 8.27% |
| Discharge to community | 48.03% |
50.57%
2.5 pts worse
|
No Different than the National Rate · Eligible stays 459 · Observed rate 45.32% · Lower 95% interval 43.42% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 352 · Denominator 352 |
| Falls with major injury | 0.57% |
0.77%
0.2 pts better
|
Numerator 2 · Denominator 352 |
| Discharge self-care score | 63.88% |
53.69%
10.2 pts better
|
Numerator 168 · Denominator 263 |
| Discharge mobility score | 57.79% |
50.94%
6.9 pts better
|
Numerator 152 · Denominator 263 |
| Pressure ulcers or injuries, new or worsened | 1.99% |
2.29%
0.3 pts better
|
Numerator 7 · Denominator 352 · Adjusted rate 2.23% |
| Healthcare-associated infections requiring hospitalization | 7.53% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 312 · Observed rate 7.05% · Lower 95% interval 5.01% |
| Staff COVID-19 vaccination coverage | 1.14% |
8.2%
7.1 pts worse
|
Numerator 3 · Denominator 263 |
| Staff flu vaccination coverage | 20.43% |
42%
21.6 pts worse
|
Numerator 48 · Denominator 235 |
| Discharge function score | 69.96% |
56.45%
13.5 pts better
|
Numerator 184 · Denominator 263 |
| Transfer of health information to provider | 98.95% |
95.95%
3 pts better
|
Numerator 94 · Denominator 95 |
| Transfer of health information to patient | 98.66% |
96.28%
2.4 pts better
|
Numerator 221 · Denominator 224 |
| Resident COVID-19 vaccinations up to date | 29.79% |
25.2%
4.6 pts better
|
Numerator 56 · Denominator 188 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.8
0.1 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.2 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.0
0.6 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.3 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.6% |
92.8%
1.2 pts worse
|
93.4%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 92.3% · Q2 92.1% · Q3 92.3% · Q4 89.7% · 4Q avg 91.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.6% |
96.1%
1.5 pts better
|
95.5%
2.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.7% |
4.5%
3.2 pts worse
|
3.3%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 10.5% · Q3 10.3% · Q4 2.6% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.4% |
4.4%
3 pts better
|
11.4%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.8% · Q3 2.8% · Q4 0.0% · 4Q avg 1.4% |
| Percentage of long-stay residents who lose too much weight | 1.6% |
5.3%
3.7 pts better
|
5.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 6.7% · 4Q avg 1.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.3% |
19.5%
11.2 pts better
|
19.6%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 6.1% · Q3 8.8% · Q4 6.5% · 4Q avg 8.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.3% |
21.6%
13.3 pts better
|
16.7%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 6.7% · Q3 9.4% · Q4 13.8% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.3%
0.3 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.6% |
20.4%
3.8 pts better
|
16.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.7% |
19.9%
3.2 pts better
|
14.9%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 12.1% · Q3 14.7% · Q4 19.4% · 4Q avg 16.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.6%
1.6 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.9%
2.9 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.9% |
26.6%
5.3 pts worse
|
19.8%
12.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.5% · Q2 32.4% · Q3 31.8% · Q4 33.8% · 4Q avg 31.9% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
4.3%
0.6 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 4.0% · Q3 5.5% · Q4 3.1% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.4% |
80.5%
8.9 pts better
|
81.7%
7.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 84.7% · Q2 86.5% · Q3 91.5% · Q4 95.0% · 4Q avg 89.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.7% |
11.6%
0.9 pts better
|
12.0%
1.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.7% · Observed 10.3% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.3% |
2.4%
0.1 pts better
|
1.6%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.4% · Q3 1.6% · Q4 4.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.2% |
75.9%
9.3 pts better
|
79.7%
5.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.8% |
20.9%
5.9 pts worse
|
23.9%
2.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.8% · Observed 25.4% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-12 · Fire 2024-06-12
5 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
9 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2023-07-13 · Fire 2023-07-13
0 health deficiencies
No concentrated health issue counts in this cycle.
18 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-03
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-10-18
F · Potential for more than minimal harm
2025-09-03
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-10-18
F · Potential for more than minimal harm
2025-09-03
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-10-18
F · Potential for more than minimal harm
2025-09-03
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-10-18
F · Potential for more than minimal harm
2025-09-03
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-10-18
F · Potential for more than minimal harm
2025-09-03
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-10-18
F · Potential for more than minimal harm
2025-09-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-10-18
F · Potential for more than minimal harm
2025-09-03
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-10-18
E · Potential for more than minimal harm
2025-09-03
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2025-10-18
E · Potential for more than minimal harm
2025-09-03
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-10-18
E · Potential for more than minimal harm
2025-09-03
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-10-18
E · Potential for more than minimal harm
2025-09-03
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-10-18
E · Potential for more than minimal harm
2025-09-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-18
E · Potential for more than minimal harm
2025-09-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-10-18
E · Potential for more than minimal harm
2025-09-03
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-10-18
E · Potential for more than minimal harm
2025-09-03
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2025-10-18
F · Potential for more than minimal harm
2024-06-12
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-07-27
F · Potential for more than minimal harm
2024-06-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-27
E · Potential for more than minimal harm
2024-06-12
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2024-07-27
E · Potential for more than minimal harm
2024-06-12
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2024-07-27
E · Potential for more than minimal harm
2024-06-12
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-07-27
E · Potential for more than minimal harm
2024-06-12
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-07-27
E · Potential for more than minimal harm
2024-06-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-27
E · Potential for more than minimal harm
2024-06-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-07-27
E · Potential for more than minimal harm
2024-06-12
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-07-27
F · Potential for more than minimal harm
2023-07-13
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-08-25
F · Potential for more than minimal harm
2023-07-13
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-08-25
F · Potential for more than minimal harm
2023-07-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-25
F · Potential for more than minimal harm
2023-07-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-25
F · Potential for more than minimal harm
2023-07-13
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-08-25
F · Potential for more than minimal harm
2023-07-13
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-08-25
F · Potential for more than minimal harm
2023-07-13
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-08-25
F · Potential for more than minimal harm
2023-07-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-25
F · Potential for more than minimal harm
2023-07-13
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-08-25
F · Potential for more than minimal harm
2023-07-13
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-08-25
F · Potential for more than minimal harm
2023-07-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-25
E · Potential for more than minimal harm
2023-07-13
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2023-08-25
E · Potential for more than minimal harm
2023-07-13
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2023-08-25
E · Potential for more than minimal harm
2023-07-13
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-08-25
E · Potential for more than minimal harm
2023-07-13
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-08-25
E · Potential for more than minimal harm
2023-07-13
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-08-25
E · Potential for more than minimal harm
2023-07-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-08-25
E · Potential for more than minimal harm
2023-07-13
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2023-08-25
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-23
F844 · Administration Deficiencies
Health
Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.
Corrected 2026-01-16
D · Potential for more than minimal harm
2025-09-18
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-10-08
E · Potential for more than minimal harm
2025-09-03
F923 · Environmental Deficiencies
Health
Have enough outside ventilation via a window or mechanical ventilation, or both.
Corrected 2025-10-18
D · Potential for more than minimal harm
2025-09-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-18
G · Actual harm
2024-06-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-27
D · Potential for more than minimal harm
2024-06-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-27
D · Potential for more than minimal harm
2024-06-12
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-07-27
D · Potential for more than minimal harm
2024-06-12
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-07-27
D · Potential for more than minimal harm
2024-06-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-27
Penalties and ownership
What sits behind the stars
$8,659
2024-06-12
Fine
Fine · fine $8,659
Fine
$0
2024-06-12
Payment Denial
Payment Denial · denial start 2024-07-09 · 18 days
18 day denial
Ownership
Peterson, Jennifer
5% Or Greater Direct Ownership Interest · Individual
Peterson, Russell
5% Or Greater Direct Ownership Interest · Individual
Ardley, Mikel
Contracted Managing Employee · Individual
Paragon Management Services Inc
Operational/Managerial Control · Organization
Peterson, Jennifer
Corporate Director · Individual
Peterson, Russell
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Eastmont
Lincoln, NE
3-star overall rating with 4-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Tabitha Nursing Home
Lincoln, NE
3-star overall rating with 3-star inspections with 10 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
St. Jane de Chantal
Lincoln, NE
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
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