Above 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 The Ambassador Nebraska City, Inc during CMS and state inspections, most recent first.
A resident admitted with spinal and esophageal conditions and intact cognition experienced progressive, significant weight loss over several months while the facility failed to complete a timely, comprehensive nutritional assessment as required by its policies. Although the care plan identified risk for altered nutrition and a dietitian later recommended supplements, the resident’s repeated refusals of ordered supplements were not evaluated, and multiple documented significant 30‑day weight losses were not followed by required re‑weighs or nutritional reassessments. Event documentation for unplanned weight loss did not include immediate interventions such as supplements or snacks, and interviews confirmed that the admission nutritional assessment was not completed within the expected timeframe and that a prior nutrition fax did not meet assessment criteria.
The facility did not report an allegation that a nurse requested medication aides to provide PRN controlled medications to the nurse for administration, instead of the aides administering the medication directly to two residents. Although an internal investigation found no evidence of missing medications or misappropriation, the incident was not reported to authorities as required by facility policy.
A facility failed to complete a thorough investigation into an allegation of potential misappropriation of PRN controlled medications. Staff interviews revealed that medication aides were asked to provide medications to a nurse rather than administering them directly to a resident, and a discrepancy of eight tablets was found in a resident's controlled drug record. The DON and administrator confirmed issues with medication documentation and accounting.
The facility failed to conduct safety assessments for residents using power lift chairs, resulting in multiple falls. Residents, including those with cognitive impairments, experienced falls due to inadequate evaluation and education on chair use. Despite interventions like gripper socks and Dycem, no comprehensive safety assessments were conducted, leading to repeated incidents.
A facility failed to monitor the side effects of Adderall XR for a resident with multiple diagnoses, including narcolepsy. The resident's care plan and medication orders lacked instructions for monitoring side effects, and interviews with staff revealed a lack of awareness about the medication's side effects.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an open wound, despite policy requirements. The resident, with multiple health conditions and moderate cognitive impairment, was not included in the EBP list. Observations showed no EBP signage or gowns, and an LPN did not use a gown during wound care. Interviews revealed the resident was not placed under EBP due to the wound being non-draining and considered short-term, but the DON later confirmed EBP should have been applied.
Failure to Complete Timely Nutritional Assessment and Respond to Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to complete a timely and comprehensive nutritional assessment and to respond appropriately to significant weight loss for one resident. The facility’s own Nutritional Assessment Policy required that a nutritional assessment be conducted upon admission within current baseline assessment timeframes and with any change in condition that placed a resident at risk for impaired nutrition. This assessment was to include usual body weight, current height and weight, usual intake and appetite, history of weight changes, clinical conditions, medications affecting nutrition, laboratory results, chewing or swallowing issues, and an estimate of calorie, protein, nutrient, and fluid needs. The policy also required the multidisciplinary team to identify, at admission, quarterly, and with changes in condition, situations that place a resident at increased risk for impaired nutrition. In addition, the facility’s Weight Recording Policy required admission and at least monthly weights, more frequent weights as needed, re-weighs for significant weight changes, and notification of the physician and dietitian for significant weight loss. The resident at issue was admitted with diagnoses including an unspecified fracture of T11–T12 vertebra, spinal stenosis, intervertebral disc degeneration of the thoracolumbar region, and esophageal obstruction, and had an intact BIMS score of 15/15. The admission MDS documented a weight of 134 pounds, and the comprehensive care plan identified a potential for altered nutrition, hydration, and weight status related to multiple medications and complex medical history. The care plan included a regular diet, weights per MD orders, monitoring of meal intakes, offering appropriate alternates, and noted that the resident refused starting an oral supplement. Despite these identified risks and the facility’s policy, record review showed that no nutritional assessment addressing usual body weight, usual intake, prior weight history, meal and snack patterns, medication effects on nutrition, preferred portion sizes, relevant labs, chewing or swallowing abnormalities, and adequacy of intake was completed until approximately three months after admission. Weight records showed a pattern of significant weight loss without appropriate follow-up as required by policy. The resident’s weight decreased from 134.4 pounds at admission to 128.8 pounds within about two weeks, a 4.17% loss, and then to 118 pounds one month later, a 7.76% loss from the prior weight, constituting significant weight loss in 30 days with no evidence of a re-weigh. A PAC note documented a 10‑pound weight loss over the last month, poor appetite, and food consistency preferences related to a Schatzki ring history, and a dietary consult was ordered. A dietitian recommended adding a magic cup or shake with meals, which was ordered, but MAR review showed the resident took the supplement for a brief period and then refused it for 38 days over 114 occurrences, with no evidence that the facility evaluated the resident’s nutritional status or response to these refusals. Subsequent weights continued to show significant losses: 112.4 pounds, then 106.2 pounds, and then 104.8 pounds over successive weigh dates, each representing additional significant 30‑day weight losses. The record contained no evidence of re-weighs or completed evaluations of nutritional needs in response to these significant changes. An Event Report for unplanned weight loss indicated the resident was not on a physician‑prescribed weight loss regimen, and immediate measures such as supplements and snacks were not identified as interventions on that form. Interviews with the Administrator and the Dietitian confirmed that no admission nutritional assessment had been completed within the expected 14‑day timeframe and that the earlier nutrition fax did not meet the criteria for a full nutritional assessment. These actions and omissions resulted in the facility failing to provide sufficient food and fluids to maintain the resident’s health as required by their policies and regulatory standards.
Failure to Report Alleged Misappropriation of Medication
Penalty
Summary
The facility failed to report an allegation of potential misappropriation of medication involving two residents. An investigation was conducted after it was alleged that a nurse requested medication aides to sign out PRN controlled medications and provide them to the nurse, rather than having the medication aide administer the medication directly to the residents. The facility's investigative report included an audit of narcotic logs, administration records, and PRN medication re-orders, with no concerns identified, and staff interviews did not reveal evidence of misappropriation. Despite these findings, the administrator confirmed in interviews that the allegation was not reported as potential misappropriation of medications to the appropriate authorities, as required by facility policy. The administrator stated that the reporter did not allege missing medications, and the facility's investigation focused on ensuring medications were not missing. However, the facility policy mandates immediate reporting of all alleged violations involving misappropriation of resident property, regardless of whether medications were found to be missing.
Failure to Thoroughly Investigate and Account for Controlled Medications
Penalty
Summary
The facility failed to ensure a thorough investigation was completed regarding an allegation of potential misappropriation of medications for one resident. An initial review of the facility's investigation revealed that a nurse had requested medication aides to sign out PRN controlled medications and provide them to the nurse, rather than having the medication aide administer the medication directly to the resident. Although an audit of narcotic logs and PRN medication administration did not initially identify concerns, subsequent staff interviews revealed that three staff members had been asked to provide PRN medications to a nurse for a resident instead of administering them directly. Further review of the Controlled Drug Record for a resident's PRN Hydrocodone showed a discrepancy in the medication count, with an unexplained difference of eight tablets between two record sheets. The DON confirmed that the number of medications on the Controlled Drug Record did not match the medications available in the cart, and the administrator acknowledged a documentation issue in accounting for controlled medications. The facility's investigation did not initially identify this discrepancy, and further investigation was acknowledged as necessary to determine the whereabouts of the missing medications.
Failure to Conduct Safety Assessments for Lift Chair Use
Penalty
Summary
The facility failed to ensure evaluations were completed for several residents to ensure the safe use of power lift chair recliners, leading to multiple incidents of falls. The facility's policies required fall risk assessments and interventions for residents identified as high risk, but these were not adequately implemented. For instance, Resident 12, who had a history of falls and was moderately cognitively impaired, experienced falls from the lift chair due to sliding on the carpet. Despite interventions like gripper socks and Dycem, no safety assessment was conducted to evaluate the resident's ability to use the lift chair safely. Similarly, Resident 7, who was severely cognitively impaired, fell from the lift chair due to confusion and inability to understand the chair controller. The resident's fall was unwitnessed, and the intervention was limited to increased safety checks. Again, no safety assessment was completed to ensure the resident's safe use of the lift chair. Resident 15, who was cognitively aware but required maximal assistance, fell from the lift chair while attempting to adjust the chair remote, resulting in significant injuries. The facility did not conduct a safety assessment prior to the incident. Other residents, such as Resident 47 and Resident 205, also experienced falls from lift chairs due to similar issues, including lack of understanding of the chair controls and improper positioning. The facility's failure to conduct safety assessments and provide adequate education on the use of lift chairs contributed to these incidents. Interviews with staff, including the Director of Nursing and Occupational Therapist, confirmed that safety assessments were not routinely conducted for residents using lift chairs, highlighting a systemic issue in the facility's approach to fall prevention and resident safety.
Failure to Monitor Side Effects of Adderall XR
Penalty
Summary
The facility failed to ensure that the side effects of Adderall XR, a stimulant medication, were monitored for Resident 33. This resident was admitted with diagnoses including stroke, multiple sclerosis, high blood pressure, and narcolepsy. Despite having an intact cognitive function as indicated by a BIMS score of 14, there were no instructions in the resident's orders to monitor for side effects of the stimulant medication. Additionally, the Comprehensive Care Plan did not mention Adderall XR or the side effects of stimulant medications. Interviews with the Director of Nursing, a Registered Nurse, and a Medication Aide revealed a lack of awareness and documentation regarding the side effects of Adderall XR. The Director of Nursing confirmed that side effects should be monitored and documented in the Medication Administration Record and the Comprehensive Care Plan, but this was not done. The Registered Nurse and Medication Aide also confirmed they were unaware of the side effects of Adderall XR, indicating a gap in staff knowledge and documentation practices.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident, identified as Resident 43, who had an open wound. Despite the facility's policy indicating that EBP should be used for residents with wounds or indwelling medical devices, Resident 43 was not included in the EBP list. The resident had been admitted with multiple diagnoses, including heart failure and type 2 diabetes, and had a moderate cognitive impairment. An open area on the resident's gluteal cleft was recorded and remained open for over a month, yet the resident was not placed under EBP. Observations revealed that there was no signage or gowns available for EBP outside or inside Resident 43's room. During a wound care procedure, an LPN did not use a gown, which is part of the EBP protocol. Interviews with the RN and DON confirmed that the resident was not placed under EBP because the wound was not draining and was considered short-term. However, the DON later acknowledged that Resident 43 should have been under EBP, indicating a lapse in following the facility's infection control policy.
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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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Nursing homes near Nebraska City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Prestige Care Center Of Nebraska City | 0.5 mi | ★★★★★ | 13 | 0 |
| The Ambassador Sidney Inc | 12.2 mi | ★★★★★ | 6 | 0 |
| Good Samaritan Society - Syracuse | 16.9 mi | ★★★★★ | 0 | 0 |
| Tabor Manor Care Center | 17.7 mi | ★★★★★ | 22 | 0 |
| Good Samaritan Society - Auburn | 20.8 mi | ★★★★★ | 10 | 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.