Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ambassador Health Of Lincoln during CMS and state inspections, most recent first.
Food service and dining staff were observed failing to follow sanitary meal service practices. A Dietary Aide had hair not fully contained, a staff member lacked a beard net, and another wore a beard net below the chin. Staff also handled food and beverages without proper hand hygiene, including after removing gloves, after touching their face, after coughing, and while serving resident meal trays and drinks.
Infection control failures were observed when an LPN and a medication aide administered gastric-tube care without the required gown under EBP, and respiratory equipment for two residents was repeatedly left uncleaned or improperly stored after nebulizer use. Staff also left an oxygen tubing setup unsecured, transported clean laundry on an uncovered cart, and failed to ensure resident water pitchers were changed and kept clean, with a visibly dirty pitcher observed and staff unaware of daily pitcher changes.
Nonworking Bathroom Ventilation in 10 Resident Rooms: Surveyors observed that the bathroom vents in 10 resident rooms did not function when tested with toilet paper. Maintenance staff later confirmed the vents were not working and was unaware of the problem, and could not provide bathroom vent check logs. Record review showed the facility policy required ventilation system audits to be maintained.
Failure to Follow Up on Resident Council Grievances: A resident council repeatedly raised concerns about housekeeping, unanswered call lights, staff not knocking before entering rooms, late meds, and lack of activities, but residents said they never received feedback or resolution. Residents also reported individual complaints, including a missing military book and housekeeping issues, with no response documented in the council minutes.
Insufficient evening and weekend activities: The facility failed to provide enough scheduled activities to meet residents’ physical, mental, and psychosocial needs. The activity calendar showed very limited weekend programming and no evening activities, and the AD confirmed there were not enough activities during those times. Three cognitively intact residents reported there was little or nothing to do in the evenings or on weekends, despite care plans and MDS data showing a preference for group activities.
A resident with intact cognition had a medication pack left unattended in the room despite a care plan requiring it to be locked up when the resident was out. Another resident had a Breztri inhaler left at bedside without an order allowing bedside self-administration, and a third resident took multiple morning meds from a bedside cup without staff present and without a documented self-administration assessment. Surveyors also observed unlocked med and treatment carts with supplies and needles left unattended, and an RN confirmed the carts should have been locked.
Staff initiated CPR on a resident who had a current physician order for Do Not Resuscitate (DNR) and was cognitively intact, thereby failing to honor the resident’s expressed wishes and legal medical orders. Documentation showed an active DNR order, yet when the resident was found unresponsive and pulseless, CPR was started. The ADM later confirmed that CPR was performed despite the DNR status, and the resident reported that resuscitation had been done against both physician orders and personal wishes, while continuing to choose DNR status.
A resident with a documented DNR order and intact cognition became unresponsive in the dining room, and staff initiated CPR despite the existing DNR. During the code, staff recognized the resident’s DNR status but continued CPR and transferred the resident to acute care. The event, which violated the resident’s expressed wishes and physician orders, was not reported to APS, even though the facility completed an internal investigation.
The facility failed to maintain proper food safety and hygiene standards, affecting 65 residents. Observations revealed improperly sealed, labeled, and dated food items in the refrigerator. Cook-E did not wear a beard net while preparing food, and Cook-F did not adhere to the 20-second handwashing policy. The CDM confirmed these practices were against facility policies.
The facility failed to maintain proper infection control practices in the laundry department, medication administration, and wound care. Observations revealed unclean areas behind washing machines, improper fan placement, and staff not wearing gowns while sorting soiled laundry. A Medication Aide handled a dropped pill with ungloved hands and did not perform hand hygiene between glove changes. During wound care, an LPN washed hands for only 12 seconds, contrary to the facility's policy requiring a minimum of 20 seconds.
A facility failed to ensure privacy and explain procedures during care for a resident with significant medical conditions, including anoxic brain injury and ventilator dependence. The podiatrist left the door open during a toenail trimming, and a respiratory therapist did not explain trach care to the resident. The facility's policy requires procedures to be explained and privacy maintained, but these were not followed.
A facility failed to accurately document a resident's use of a BiPAP machine in the MDS, despite observations and interviews confirming its use. The resident, diagnosed with COPD and hypotension, was observed with BiPAP equipment improperly stored, and the MDS Nurse confirmed the omission in documentation.
A facility failed to follow a physician's order for oxygen administration for a resident with acute respiratory failure. The resident was supposed to receive oxygen at 1 LPM continuously, but records showed administration at 2 LPM multiple times without documentation or physician notification. Observations confirmed the resident received higher oxygen levels than prescribed. Interviews revealed no documentation for the increase, and the resident reported shortness of breath without requesting more oxygen.
Food Service Staff Failed to Maintain Hair Restraints and Hand Hygiene
Penalty
Summary
Food service practices were observed to be out of compliance with sanitary standards during meal preparation and distribution. In the kitchen, a Dietary Aide was observed with hair on their shoulders and not contained in a hat or hairnet, and another staff member was observed without a beard net despite visible facial hair. A beard net was also observed worn below the chin and not covering the facial hair. During food handling, a staff member doffed gloves, picked up an item off the floor, did not perform hand hygiene, and then donned new gloves. During meal service in the dining room, multiple staff members served beverages and meal trays without completing hand hygiene. One Medication Aide held a coffee cup by the rim with bare hands, filled it with hot water, added a tea bag, and served it to a resident. Another staff member coughed into a jacket, touched their face, had hair hanging over the face during meal service, and did not perform hand hygiene. Additional staff were observed serving trays without hand hygiene before starting meal service or after moving a resident wheelchair and setting up a meal tray, and one staff member’s hair touched a resident meal tray while it was being served.
Infection Control Failures With Tube Care, Respiratory Equipment, Laundry, and Water Service
Penalty
Summary
The facility failed to follow its infection prevention and control practices during gastric-tube care. On 05/11/2026, an LPN administered feeding through Resident 89’s gastric tube while the resident had an Enhanced Barrier Precautions sign posted on the door, but the LPN was not wearing a gown. The LPN later confirmed that a gown should have been worn. In a separate observation on 05/07/2026, a medication aide administered gastric-tube medications to Resident 24 without wearing a gown, and both the medication aide and a rehab nurse confirmed that a gown should have been worn for that task. Facility policy identified feeding tubes as an indication for Enhanced Barrier Precautions during high-contact resident care activities. The facility also failed to keep respiratory equipment clean and stored to prevent cross contamination. Resident 16’s nebulizer tubing, mask, and chamber were repeatedly observed connected to the nebulizer machine with fluid still in the chamber and the equipment left on the bedside nightstand or recliner over multiple observations. The facility’s respiratory equipment storage policy required nebulizer circuits to be stored in a plastic bag between uses, and staff confirmed the chamber and mask should have been rinsed and stored properly after use. Resident 77’s nebulizer treatment equipment was also observed repeatedly left uncontained in the recliner, with the tubing and chamber exposed and no proper bagged storage in place, despite treatment orders directing that the nebulizer canister be emptied, rinsed, and air dried after each use. Additional infection control concerns were observed with other resident care and facility practices. An oxygen tank in Resident 47’s room had tubing hanging over the walker handle rather than being stored in a plastic bag when not in use. A laundry cart was observed uncovered while laundry staff passed out clean laundry, even though facility policy required covered transport. Resident 47 also reported that water pitchers and cups were not being changed out, and a visibly dirty water pitcher was observed on the resident’s tray table; the facility’s water distribution policy required pitchers to be changed every 24 hours and fresh water to be provided at least every 24 hours. The Infection Preventionist and Dietary Manager were unaware that the resident water pitchers were being changed and cleaned daily.
Nonworking Bathroom Ventilation in 10 Resident Rooms
Penalty
Summary
The facility failed to ensure that the ventilation systems were operational in 10 resident bathrooms in Rooms 113 through 122. During a facility tour, surveyors observed that the bathroom vents in these rooms did not suck up one ply square of toilet paper, indicating they were not working. A later observation with Maintenance Staff confirmed that the bathroom vents in these resident rooms were not working, and the staff member was unaware of the problem and unable to provide resident bathroom vent check logs. Record review of the facility policy titled Ventilation System Check and Auditing, dated 3/8/2023, showed that ventilation system audits were to be maintained.
Failure to Follow Up on Resident Council Grievances
Penalty
Summary
The facility failed to provide prompt follow-up and communication regarding complaints and grievances brought to Resident Council meetings. A record review of the facility grievance policy stated that grievances and recommendations from resident councils concerning resident care would be considered, and that actions on such issues would be discussed with the resident/family group with the facility’s response and rationale documented in writing. During interviews, a resident reported filing a complaint about a missing military book and stated nothing ever happened, and another resident reported filing a complaint about housekeeping with no response. The Administrator confirmed the facility schedules resident council meetings with residents who are cognitively capable of participating in the discussion. At a resident council meeting, six residents discussed ongoing concerns including inconsistent housekeeping, call lights not being answered for over an hour, activity calendars not being delivered routinely, requests for more age-appropriate activities, and a request for additional outside seating toward the back of the building. All residents in the group stated they did not receive follow-up or feedback about their concerns and that issues were discussed with leaders but did not go anywhere. Record review of resident council meeting minutes from multiple months showed repeated concerns such as short staffing, late medications, call lights being turned off or not answered, staff not knocking before entering rooms, housekeeping not cleaning bathrooms, staff phone use, and requests for courtyard furniture and outings, with no corrective action or follow-up indicated in the minutes.
Insufficient evening and weekend activities
Penalty
Summary
The facility failed to ensure activities were provided to meet the physical, mental, and psychosocial well-being of 3 sampled residents. Review of the facility’s activity program policy stated that activities were designed to meet each resident’s interests and well-being, but review of the March, April, and May 2026 activity calendars showed only one music activity scheduled on weekends and no evening activities scheduled for each month. The Activities Director confirmed there were not enough activities in the evenings or on the weekends and stated a desire to do more activities during those times but had not implemented them yet. Resident 14 was cognitively intact with a BIMS of 15, had no behaviors or rejection of care, and had documented importance placed on doing things with groups of people; the resident stated there were only activities for the old people there. Resident 47 was also cognitively intact with a BIMS of 15, had no behaviors or rejection of care, and had documented importance placed on group activities; the resident stated there were no activities in the evenings or on weekends. Resident 66 had a BIMS of 15 and reported being able to keep busy in the evenings but feeling there was nothing to do on weekends, describing the calendar’s independent activities as a cart of books and items outside the Activities Director’s office and stating that planned weekend activities would be great.
Unsecured medications and unlocked carts
Penalty
Summary
Medications and biologicals were not stored and secured in accordance with facility policy and accepted practice for multiple residents. Resident 30, who had a BIMS score of 15 and was documented as cognitively intact, had a care plan stating the resident would self-administer medications safely and keep medications in the room and locked up when out of the room. However, a medication pack was observed on the bedside stand while the resident was out of the room, and both the resident and LPN confirmed the pack was left unattended. The DON later confirmed medications should not be left unattended and that the care plan and policy should be followed. Resident 16 had a Breztri inhaler observed on the bedside table on multiple occasions. The resident’s self-medication assessment allowed an Albuterol inhaler at bedside, but the record review showed no order allowing Breztri to be self-administered or left at the bedside. A rehab nurse confirmed the Breztri inhaler should not have been at bedside. In addition, Resident 10 had multiple morning oral medications ordered, but there was no documentation of a self-administration assessment. During observation, Resident 10 had a medication cup with many pills on the bedside table and took the medications without a staff member present to verify administration. The facility also failed to keep medication and treatment carts locked when unattended. A medication cart on unit 3 was observed unlocked with baskets containing a glucometer, lancets, alcohol pads, and cotton balls on top, and a treatment cart on Station 3 was observed unlocked with containers of needles left unattended on top and insulin pens and other items in the drawer. RN-D later locked both carts and confirmed the carts should have been locked. The facility policy stated medications must be stored securely and never left unattended, and the medication administration policy stated medication should never be left with the resident to be taken later.
CPR Performed Despite Resident’s Active DNR Order
Penalty
Summary
Facility staff failed to honor a resident’s right to self-determination and to follow physician orders by initiating cardiopulmonary resuscitation (CPR) on a resident who had a current Do Not Resuscitate (DNR) order. The resident’s Minimum Data Set dated 3/4/2026 showed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. A physician order report dated 2/11/2026 documented a DNR order for this resident. However, a nursing progress note dated 2/23/2026 at 9:47 AM recorded that the resident was found unresponsive and without a pulse, and CPR was initiated by facility staff. In an interview, the Administrator confirmed that CPR was started despite the resident’s DNR status and that CPR should not have been initiated due to the resident’s wishes. In a separate interview, the resident confirmed that CPR had been performed against physician orders and personal wishes, stated being happy to be alive, but affirmed not wanting CPR to be initiated again and remained a DNR.
Failure to Honor DNR Order and Report Adverse Event to APS
Penalty
Summary
The deficiency involves the facility’s failure to report an adverse event that violated a resident’s rights when CPR was performed despite an active Do Not Resuscitate (DNR) order. Record review showed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 on a recent MDS, indicating the resident was cognitively intact. The physician order report documented a current DNR order, a legally binding medical document instructing that CPR not be performed if the resident’s heart or respirations ceased. On the date of the incident, nursing progress notes documented that the resident was found unresponsive and without a pulse, and CPR was initiated. Facility documentation of the Code Blue event showed that the resident became unresponsive in the dining room and CPR was started. During the resuscitation, staff noted the resident’s DNR status but continued CPR, and the resident was later transferred to acute care. A review of the facility’s 2026 Reportable Events log revealed that this event, including the investigation, was not reported to Adult Protective Services (APS). In interviews, the Administrator confirmed that CPR was initiated despite the resident’s DNR status and that the event was not reported to APS, and the resident confirmed that CPR had been performed against physician orders and personal wishes, while stating they remained DNR and would not want CPR again.
Food Safety and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to proper food safety and hygiene standards in the kitchen, which could potentially affect 65 of the 71 residents who consume food prepared there. During an initial kitchen tour, it was observed that several food items, including Jello, carrot cake, rainbow sprinkles, cereals, vanilla instant pudding, brown sugar, and cocoa powder, were not properly sealed, labeled, or dated in the walk-in refrigerator. The Certified Dietary Manager (CDM) confirmed that these items should have been sealed, labeled, and dated according to the facility's policies. Additionally, there were issues with staff hygiene practices. Cook-E was observed preparing food without wearing a beard net, despite having a beard length of 1/2 to 3/4 inch, which was confirmed by the CDM as not being a 'shadow beard' that would exempt the need for a beard net. Furthermore, Cook-F was observed washing hands for less than the required 20 seconds on multiple occasions while preparing food. The facility's corporate dietary handwashing policy mandates a minimum of 20 seconds for handwashing, which was not adhered to by Cook-F.
Infection Control Deficiencies in Laundry, Medication Administration, and Wound Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices in the laundry department, medication administration, and wound care. Observations revealed that the area behind the washing machines was not kept clean, with a large amount of gray fuzzy substance, debris, and a hanger present. Additionally, a fan was improperly positioned, blowing air from the dirty side to the clean side of the laundry room. Staff were observed not wearing gowns while sorting soiled laundry, contrary to the facility's procedures that require gloves and fluid-resistant gowns to prevent cross-contamination. During medication administration, a Medication Aide was observed handling a dropped pill with ungloved hands and placing it back into a medication cup with other pills. The aide then placed the cup into their scrub pocket without performing hand hygiene between glove changes. The facility's policy requires handwashing or sanitization between each resident when passing medications, which was not adhered to. The Director of Nursing confirmed that hand sanitizer was available but not utilized as expected. In wound care, a Licensed Practical Nurse performed handwashing for only 12 seconds, contrary to the facility's policy that mandates a minimum of 20 seconds. The nurse was observed conducting wound care for a resident with a history of moisture-associated skin damage, using hand sanitizer gel between glove changes. The facility's handwashing policy emphasizes the importance of thorough handwashing to prevent the spread of infection, which was not followed in this instance.
Failure to Ensure Privacy and Procedure Explanation
Penalty
Summary
The facility failed to ensure that staff explained procedures and provided privacy during resident care for one resident. The facility's dignity policy mandates that residents be treated with dignity and respect, with procedures explained before they are performed, and privacy maintained during personal care and treatment procedures. However, during a podiatry exam, the podiatrist trimmed the resident's toenails with the room door open, making the procedure visible from the hallway. Additionally, a respiratory therapist performed tracheostomy care on the resident without explaining the procedure to the resident beforehand. The resident involved had significant medical conditions, including anoxic brain injury, tracheostomy status, acute and chronic respiratory failure with hypoxia, and dependence on a ventilator. The resident was also cognitively impaired, as indicated by a Brief Interview for Mental Status score of 99, suggesting the resident was rarely or never understood. Despite these conditions, the staff did not adhere to the facility's policy of explaining procedures and ensuring privacy, as confirmed by the Director of Nursing.
Inaccurate MDS Documentation for BiPAP Use
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for a resident, specifically regarding the use of a BiPAP machine. Resident 14, who was admitted with a primary diagnosis of COPD and hypotension, was observed using a BiPAP machine with nasal pillows connected to the tubing and hanging from a hook on the wall. Despite the resident's request to store the equipment in this manner, the MDS did not reflect the use of the BiPAP machine in Section O, which is required to document special treatments and procedures. Interviews with the resident and facility staff, including an LPN and the MDS Nurse, confirmed that the resident was educated on best practices for storing the equipment to prevent cross-contamination. However, the MDS Nurse acknowledged that the MDS did not accurately document the resident's use of the BiPAP machine, despite following the RAI Manual's guidance. This oversight in documentation led to a deficiency in accurately assessing and recording the resident's treatment needs.
Failure to Follow Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to adhere to the physician's order for the administration of oxygen for a resident, identified as Resident 28. The physician's order specified that oxygen should be administered at 1 liter per minute (LPM) continuously, with instructions to update the primary care provider if more than 1 LPM was needed. However, the Medication Administration Records for August, September, and October 2024 showed that oxygen was administered at 2 LPM multiple times without documentation or notification to the physician. Observations on November 6 and 7, 2024, confirmed that the resident was receiving oxygen at 2 LPM and 1.5 LPM, respectively, which was not in accordance with the physician's order. Interviews with the LPN and the Director of Nursing revealed that there was no documentation for the increase in oxygen levels, and the physician was not notified of the changes. The resident, who was admitted in December 2017 and diagnosed with acute respiratory failure with hypoxia, reported experiencing shortness of breath and did not request an increase in oxygen. Despite the resident's oxygen saturation levels not dropping below 91%, the facility's failure to follow the prescribed oxygen administration protocol and lack of communication with the physician constituted a deficiency.
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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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Nursing homes near Lincoln
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St. Jane De Chantal | 0.5 mi | ★★★★★ | 27 | 0 |
| Holmes Lake Rehabilitation & Care Center | 1.1 mi | ★★★★★ | 10 | 0 |
| Eventide Lincoln Care Center | 1.2 mi | ★★★★★ | 33 | 0 |
| Emerald Nursing & Rehab Brookside Llc | 1.7 mi | ★★★★★ | 26 | 0 |
| Sumner Place | 1.8 mi | ★★★★★ | 0 | 0 |
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