Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Ambassador Health Of Lincoln during CMS and state inspections, most recent first.
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.
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.
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.
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 | ★★★★★ | 4 | 0 |
| Emerald Nursing & Rehab Brookside Llc | 1.7 mi | ★★★★★ | 27 | 0 |
| Sumner Place | 1.8 mi | ★★★★★ | 0 | 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.