Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 The Ambassador Sidney Inc during CMS and state inspections, most recent first.
Failure to Provide Required Medicare Non-Coverage Notice: A resident with moderate cognitive impairment and diagnoses including stroke, atrial fibrillation, and paralysis was discharged from Medicare A services without receiving the required NOMNC or SNF ABN. The facility record showed the resident and/or family did not receive the 48-hour advance notice of financial responsibility before Medicare-covered services ended, and the Administrator and Social Services Director acknowledged the missing documents.
Failure to provide ordered restorative nursing services for a resident with quadriplegia and limited ROM. The resident’s care plan addressed PROM for the upper extremities but did not include lower extremity PROM or communication, even though nursing orders required daily PROM and daily restorative communication. The Restorative TAR showed the programs were documented only 8 of 30 days, with many missed or blank entries, and the resident reported not receiving services for several days. Staff said the RNA was often pulled to the floor during staffing shortages, and the DON and Administrator acknowledged the lack of documentation.
Wheelchair Transport Without Foot Pedals: A resident with severely impaired cognition, dementia, osteoporosis, and extensive ADL assistance needs was transported in his wheelchair by a CNA without foot pedals attached. The CNA later acknowledged the wheelchair should not have been used that way, and a CMA and DON stated staff should ensure foot pedals are on before pushing a resident in a wheelchair.
A resident with ESRD, atrial fibrillation, and HTN did not consistently have required pre-HD and post-HD site assessments and VS documented on dialysis days. Records showed the Monday/Wednesday/Friday assessments were missing for multiple dates, and the resident stated staff did not always take VS before dialysis because she usually left early. The DON stated staff should have been ensuring the assessments were consistently completed and sent with the resident and returned.
Infection control practices were not followed during care for a resident with an indwelling urinary catheter and a history of UTIs. A CNA carried used PPE out of the room without hand hygiene, and staff later lifted the catheter drainage bag above the resident's bladder while dressing the resident. The resident had diagnoses including obstructive uropathy, DM, Alzheimer's disease, and non-Alzheimer's dementia, and staff confirmed the PPE and catheter-handling actions were not appropriate.
Staff failed to follow proper infection control practices during meal service by using the same pair of gloves to touch both food and non-food surfaces while preparing sandwiches for residents. This practice did not comply with the facility's policy requiring single-use gloves.
A resident with severe cognitive and physical impairments, including a history of stroke and a below-the-knee amputation, did not consistently receive required fall prevention interventions such as proper placement of a fall mat and wheelchair. Observations showed these interventions were not always in place as directed by the care plan, and staff interviews revealed inconsistent understanding and application of the interventions.
A resident with severe self-care deficits and impaired communication experienced increased secretions, coughing, and emesis over several days. Staff did not implement a standing PRN order for suctioning or consistently monitor and document vital signs during this period. Interviews revealed that LPNs and the DON were unaware of the suctioning order and did not follow the facility's respiratory protocol for monitoring respiratory symptoms.
Nursing staff documented completion of a wound care treatment for a resident with a pressure ulcer before the treatment was actually performed. Certified nurse aides provided peri care and changed the resident's brief without applying the prescribed barrier cream or notifying the nurse, and the LPN later confirmed the treatment had not been done at the time it was charted. Facility policy requires accurate and timely documentation, which was not followed.
Staff failed to follow proper hand hygiene and Enhanced Barrier Precautions during care for two residents, including one with a suprapubic catheter and another with a pressure ulcer. In both cases, staff did not perform hand hygiene between glove changes or after touching potentially contaminated surfaces, contrary to facility policy and expectations.
A resident with severe cognitive deficits and pressure wounds did not receive wound care treatments as ordered. Observations revealed that treatment patches on the coccyx were not changed as scheduled, and the sore on the right ankle was uncovered. The DON acknowledged the oversight and discrepancies in documentation.
A resident with severe cognitive deficits and a history of acute kidney injury and chronic UTIs was not provided adequate fluids or monitored for intake and output, despite having a urinary catheter. Observations showed a lack of fluids in the resident's room, and staff admitted to not providing thickened liquids due to concerns about the resident's ability to manage them. The facility's policy on fluid management was not followed, leading to the resident's hospitalization for acute kidney injury and a complicated UTI.
Failure to Provide Required Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide residents and families with 48-hour advance notice of financial responsibility when Medicare Part A services were scheduled to be discontinued for one of three residents reviewed, Resident #53. The resident had a BIMS score of 8/15, indicating moderate cognitive impairment, and diagnoses included stroke, atrial fibrillation, and paralysis of one side of the body. The clinical record showed the resident was admitted with Medicare A as the payor source and was discharged from Medicare A services on 12/30/25. The Skilled Nursing Facility Beneficiary Protection Notification Review form showed Resident #53 did not receive the Notice of Medicare Non-Coverage (NOMNC) or the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN). The Administrator and Social Services Director acknowledged that the proper documents were not provided for signature prior to discharge from Skilled Medicare A services. The facility policy stated residents would be notified of the ending of Medicare services no later than 48 hours before termination of services.
Failure to Provide Ordered Restorative Nursing Services
Penalty
Summary
The facility failed to develop and carry out restorative programs to maintain a resident’s strength, range of motion (ROM), and communication needs based on the comprehensive assessment. Resident #3 had diagnoses of quadriplegia, anxiety disorder, and depression, with functional limitations of ROM in all extremities. The MDS dated 12/16/25 showed a BIMS score of 14/15, indicating normal cognition, and documented that the resident received only 1 day of passive range of motion (PROM) and 1 day of communication for at least 15 minutes in the prior 7 days. The care plan identified contractures related to quadriplegia and included PROM exercises for the hands, wrists, elbows, and shoulders daily, but it did not address restorative programs for the lower extremities or communication. Nursing orders required daily PROM and daily restorative communication, yet the Restorative TAR for 2/9/26 through 3/11/26 showed both programs were provided only 8 of 30 days, with missed entries due to staff running out of time, the resident sleeping, visitors, staff not being available, and 14 days with no entries. The resident stated on 3/9/26 that she had not received restorative services in the past 3 days and believed it was related to staffing. Staff reported that the RNA was often pulled to the floor when staffing was short, which could cause residents to miss programs or receive decreased time, and the DON and Administrator acknowledged there was no documentation showing completion of the restorative services.
Wheelchair Transport Without Foot Pedals
Penalty
Summary
The facility failed to ensure a resident’s wheelchair was equipped with foot pedals during transport. Resident #22 had an MDS assessment showing a BIMS score of 07 out of 15, indicating severely impaired cognition, along with diagnoses of diabetes mellitus, non-Alzheimer’s dementia, and osteoporosis. The assessment also showed the resident required supervision with eating, moderate assistance with oral and personal hygiene, upper body dressing, tub and toilet transfers, rolling left-to-right, and sitting-to-lying, and maximal assistance with all other ADLs and other forms of mobility. The resident used a wheelchair and walker during the 7-day look-back period, and the care plan stated the resident was independent with locomotion in his wheelchair and staff helps him at times. On 3/10/26, a CNA transported Resident #22 in his wheelchair from the dining room to the lobby without foot pedals attached. The CNA later stated she should not have pushed the resident in his wheelchair because it did not have foot pedals attached. A CMA stated staff should make sure the foot pedals are on a resident’s wheelchair before transporting them in it. The facility’s Wheelchair General Guidelines policy stated wheelchairs should be safe, properly maintained, and appropriate for each resident’s needs, and that residents’ feet should be positioned properly on footrests when seated. The DON stated that if the resident asked to be pushed in the wheelchair, staff should have reminded him they could not push him without pedals, and if he did not ask to be pushed, staff should not have pushed him.
Inconsistent Pre- and Post-Dialysis Assessments
Penalty
Summary
The facility failed to consistently complete required pre-hemodialysis and post-hemodialysis assessments for a resident who received dialysis. Resident #2 had diagnoses including atrial fibrillation, hypertension, ESRD, and a thyroid disorder, and the MDS indicated a BIMS score of 14 out of 15 with intact cognition. The resident was independent with eating, required supervision with oral hygiene, and needed varying levels of assistance with personal care and mobility. The care plan included a dialysis focus and directed staff to coordinate the resident’s dialysis schedule and transportation. Review of progress notes, vital signs documentation, the EHR, and staff interviews showed that the resident’s Monday, Wednesday, and Friday pre-dialysis and post-dialysis site assessments and vital signs were not consistently documented between 1/28/26 and 3/09/26. The resident stated that staff did not always take vital signs before dialysis because she usually left at 5:20 AM. The EHR later included orders for pre-dialysis and post-dialysis assessments and for sending the communication form to the hemodialysis facility every Monday, Wednesday, and Friday, and the DON stated staff should have been ensuring the assessments were consistently completed and sent with the resident and returned.
Infection Control Lapses During Catheter Care and PPE Removal
Penalty
Summary
Infection prevention and control practices were not implemented during care for a resident with an indwelling urinary catheter. The resident had diagnoses including obstructive uropathy, diabetes mellitus, Alzheimer's disease, and non-Alzheimer's dementia, and the MDS indicated a BIMS score of 14 out of 15, with the resident otherwise requiring extensive assistance with ADLs and having an indwelling catheter in the 7-day look-back period. The care plan identified the catheter and a history of UTIs and directed staff to provide catheter care on rounds and as needed. During observation of morning care, staff performed hygiene and catheter care, but one CNA removed PPE from the resident's room and carried it out without performing hand hygiene. Later, while dressing the resident, staff lifted the urinary catheter drainage bag above the resident's bladder and threaded it through the pant leg before putting on the resident's pants. The drainage bag had also been observed lying on the floor beside the bed before being picked up and hung on the bedframe. Staff interviews confirmed the gown should not have been taken out of the room and that the catheter bag should not have been raised above the resident's body during dressing. The facility policy on Standard Precautions stated soiled gowns are to be removed promptly and hands washed to avoid transfer of microorganisms.
Inadequate Infection Control During Meal Service
Penalty
Summary
Staff failed to use adequate infection control practices during meal service, as observed during lunch meal preparation. A dietary aide donned gloves and then touched multiple surfaces, including a bread bag, bread slices, utensils, and a cheese container, without changing gloves between tasks. The same gloved hands were used to handle both food items and non-food contact surfaces, contrary to the facility's glove use policy, which requires gloves to be used only once and discarded after use. These actions occurred while preparing sandwiches for residents, with a reported facility census of 40 residents at the time.
Failure to Consistently Implement Fall Prevention Interventions
Penalty
Summary
A deficiency occurred when staff failed to follow fall prevention interventions for a resident with significant cognitive and physical impairments. The resident was dependent on staff for all activities of daily living, had a history of cerebrovascular accident, anxiety, a below-the-knee amputation, and was receiving hospice care. The resident's care plan and fall risk assessments identified specific interventions, including placing a fall mat next to the bed and ensuring the wheelchair was positioned and locked near the bed. However, multiple observations revealed that these interventions were not consistently implemented. The fall mat was sometimes folded against the wall or not placed correctly, and the wheelchair was not always positioned as required by the care plan. Interviews with staff indicated inconsistent knowledge and application of the resident's fall interventions, with some staff referencing care plans, binders, or posted notes for guidance. The Director of Nursing confirmed that staff were expected to follow the interventions outlined in the care plan. Despite these expectations, the facility did not have a policy specifically related to following the care plan, contributing to the failure to consistently implement fall prevention measures for the resident.
Failure to Provide PRN Suctioning and Monitor Vitals During Respiratory Distress
Penalty
Summary
Staff failed to implement necessary respiratory interventions for a resident with significant self-care deficits, including cerebral palsy, seizure disorder, and dysphagia, who was dependent on staff for all activities of daily living and had impaired communication. The resident experienced increased secretions, frequent coughing, emesis, and congestion over several days, as documented in nursing notes. Despite a standing PRN order for suctioning with a Yankauer for secretions the resident could not clear, there was no evidence that suctioning was performed or that staff were aware of the order. Additionally, staff did not consistently monitor or document vital signs during the period of increased respiratory symptoms, with only a single set of vitals reported to the physician and no follow-up vitals recorded for two days. Interviews with LPNs and the DON revealed a lack of awareness regarding the PRN suctioning order and uncertainty about the location of suctioning supplies. The DON acknowledged that the order had been in place since a previous sinus infection and that staff likely did not know it existed. The facility's respiratory protocol required monitoring of respiratory symptoms and vital signs, but this was not consistently followed during the resident's episode of increased secretions and respiratory distress.
Inaccurate Documentation of Wound Care Treatment
Penalty
Summary
Nursing staff failed to accurately document the timing of a wound treatment for one resident who was admitted following a traumatic subdural hemorrhage and presented with a pressure sore to the coccyx. The resident had a physician's order for Calmoseptine ointment to be applied three times daily to the sacral pressure ulcer. On the morning in question, certified nurse aides provided peri care and changed the resident's brief without applying the prescribed barrier cream or notifying the nurse to complete the treatment. The resident was then transferred to the dining room without the wound care being performed at the scheduled time. The Medication Administration Record/Treatment Administration Record (MAR/TAR) indicated that the wound treatment was documented as completed, with a note that it was charted late but done on time. However, when questioned, the LPN assigned to the resident confirmed that the morning treatment had not yet been performed at the time it was documented. The facility's policy requires accurate and thorough documentation of all care provided, including the correct date and time for each entry, which was not followed in this instance.
Failure to Implement Hand Hygiene and Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement proper infection prevention and control practices during resident care for two residents. In one instance, a resident with severe cognitive impairment, renal insufficiency, and an indwelling suprapubic catheter required Enhanced Barrier Precautions (EBP) and hand hygiene as part of their care plan. During observed care, a CNA performed hand hygiene and donned PPE at the start, but after removing gloves and donning new ones, did not perform hand hygiene between glove changes while assisting the resident with dressing, grooming, and hygiene tasks. Both the Director of Nursing and the Administrator confirmed that hand hygiene should have been performed between glove changes. In another case, a resident admitted after hospitalization for a traumatic subdural hemorrhage and with a Stage II pressure sore required EBP during care. During observed care, a CNA removed a soiled brief with gloved hands and, before changing gloves or performing hand hygiene, reached into her pocket to use a walkie talkie. The DON stated that gloves should have been changed and hand hygiene performed before touching personal items. Facility policies required single-use gloves and specified EBP for high-contact care activities, including wound care.
Failure to Provide Ordered Wound Care
Penalty
Summary
The facility failed to provide wound care treatments as ordered for a resident with pressure wounds on her coccyx and inner ankle. The resident, who had severe cognitive deficits and was totally dependent on staff for care, had treatment orders for her wounds that were not followed. During an observation, it was noted that the treatment patches on her coccyx were not changed as per the schedule, and the sore on her right ankle was not covered with a bandage as required by the treatment order. The resident's care plan indicated a potential for pressure ulcers due to her condition, which included limited range of motion and incontinence. Despite this, the facility did not adhere to the prescribed wound care protocols. The Director of Nursing acknowledged the oversight and noted discrepancies in the documentation of wound care treatments, indicating a lapse in following the facility's wound care policy.
Inadequate Fluid Management for Resident with Urinary Catheter
Penalty
Summary
The facility failed to provide adequate fluids and monitor the intake and output for a resident with a history of acute kidney injury and chronic urinary tract infections. The resident, who had severe cognitive deficits and was dependent on staff for toileting and showering, was admitted with a urinary indwelling catheter. Despite the care plan indicating the need to monitor and encourage fluid intake, observations showed that the resident often had no fluids available in his room, and his fluid intake was significantly below the required daily amount. The nursing notes and staff interviews revealed that the resident's fluid intake was not adequately monitored or encouraged. Staff members admitted to not providing thickened liquids in the resident's room, citing concerns that he might try to fill the glass with regular water. The resident expressed that he would like to have fluids in his room, and staff acknowledged that they often skipped his room during water passes. The Director of Nursing was unaware of the low intake and output averages, indicating a lack of oversight in monitoring the resident's fluid status. The facility's policy on intake and output, which mandates providing adequate fluids and monitoring based on the resident's condition, was not followed. The resident's average daily fluid intake was far below the normal range, and his urine output was also low, suggesting inadequate hydration. This deficiency in care contributed to the resident's hospitalization for acute kidney injury and complicated urinary tract infection, highlighting a significant lapse in the facility's responsibility to ensure proper hydration and monitoring for residents with specific medical needs.
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What surveyors actually found near you
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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.
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sidney
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tabor Manor Care Center | 10.7 mi | ★★★★★ | 22 | 0 |
| Prestige Care Center Of Nebraska City | 11.7 mi | ★★★★★ | 13 | 0 |
| The Ambassador Nebraska City, Inc | 12.2 mi | ★★★★★ | 1 | 0 |
| Garden View Care Center | 13.9 mi | — | 45 | 2 |
| Accura Healthcare Of Shenandoah | 14.3 mi | ★★★★★ | 16 | 0 |
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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.