Cycle 1
Health 2024-11-13 · Fire 2024-11-13
5 health deficiencies
Top issue: Infection Control (1 deficiency)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Lincoln, NE
Ambassador Health of Lincoln
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
4405 Normal Blvd, Lincoln, NE
(402) 488-2355
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
122
Certified beds
Average residents
80
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ambassador Health
Operator or chain grouping
Approved since
1984-02-24
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
4 facilities
Chain averages 4 overall / 4 health / 4 staffing / 3 quality stars
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
0.96
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
1.43
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
3.13
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
5.52
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
2.39
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
4.71
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.49
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.76
CMS adjusted RN staffing hours
Adjusted total hours
4.40
CMS adjusted total nurse staffing hours
Case-mix index
1.72
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,698
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29
Composite VBP score used to determine payment impact.
Payment multiplier
0.9853
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.94
Baseline 18.21% · Performance 20.07% · Measure score 2.94 · Achievement 2.94 · Improvement 0
Healthcare-associated infections
0
Baseline 6.97% · Performance 8.17% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.48
Baseline 58.42% · Performance 41.28% · Measure score 5.48 · Achievement 5.48 · Improvement 4.60
Adjusted total nurse staffing
3.18
Baseline 3.86 hours · Performance 3.98 hours · Measure score 3.18 · Achievement 3.18 · Improvement 0.13
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.48% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 184 · Observed rate 10.87% · Lower 95% interval 7.17% |
| Discharge to community | 56.99% |
50.57%
6.4 pts better
|
No Different than the National Rate · Eligible stays 174 · Observed rate 51.15% · Lower 95% interval 50.27% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99.07% |
95.27%
3.8 pts better
|
Numerator 107 · Denominator 108 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 107 |
| Discharge self-care score | 43.42% |
53.69%
10.3 pts worse
|
Numerator 33 · Denominator 76 |
| Discharge mobility score | 48.68% |
50.94%
2.3 pts worse
|
Numerator 37 · Denominator 76 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 107 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.17% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 103 · Observed rate 10.68% · Lower 95% interval 4.79% |
| Staff COVID-19 vaccination coverage | 5.37% |
8.2%
2.8 pts worse
|
Numerator 8 · Denominator 149 |
| Staff flu vaccination coverage | 42.05% |
42%
About the same
|
Numerator 74 · Denominator 176 |
| Discharge function score | 55.26% |
56.45%
1.2 pts worse
|
Numerator 42 · Denominator 76 |
| Transfer of health information to provider | 96.55% |
95.95%
0.6 pts better
|
Numerator 28 · Denominator 29 |
| Transfer of health information to patient | 96.49% |
96.28%
0.2 pts better
|
Numerator 55 · Denominator 57 |
| Resident COVID-19 vaccinations up to date | 27.59% |
25.2%
2.4 pts better
|
Numerator 16 · Denominator 58 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.8
0.2 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 2.5 · Expected 2.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
2.0
1.6 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.4 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.5% |
92.8%
1.3 pts worse
|
93.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 77.6% · Q2 87.7% · Q3 100.0% · Q4 100.0% · 4Q avg 91.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.4% |
96.1%
2.3 pts better
|
95.5%
2.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
4.5%
2.8 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.5% · Q3 0.0% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.9% |
4.4%
1.5 pts better
|
11.4%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.0% · Q3 4.2% · Q4 3.6% · 4Q avg 2.9% |
| Percentage of long-stay residents who lose too much weight | 4.2% |
5.3%
1.1 pts better
|
5.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 3.9% · Q3 5.8% · Q4 5.2% · 4Q avg 4.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 36.7% |
19.5%
17.2 pts worse
|
19.6%
17.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.2% · Q2 36.5% · Q3 35.2% · Q4 39.7% · 4Q avg 36.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.4% |
21.6%
4.2 pts better
|
16.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 16.7% · Q3 16.2% · Q4 18.4% · 4Q avg 17.4% · 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 | 13.8% |
20.4%
6.6 pts better
|
16.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 10.5% · 4Q avg 13.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.7% |
19.9%
5.2 pts better
|
14.9%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 9.5% · Q3 20.5% · Q4 13.0% · 4Q avg 14.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.4% |
1.6%
0.8 pts worse
|
1.0%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 5.8% · Q4 1.8% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.6% |
2.9%
0.3 pts better
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.6% · Q3 3.6% · Q4 3.2% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.1% |
26.6%
2.5 pts better
|
19.8%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.0% · Q2 23.9% · Q3 12.3% · Q4 28.9% · 4Q avg 24.1% |
| Percentage of long-stay residents with pressure ulcers | 4.8% |
4.3%
0.5 pts worse
|
5.1%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 5.3% · Q3 3.2% · Q4 7.2% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.8% |
80.5%
12.3 pts better
|
81.7%
11.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.1% · Q2 91.9% · Q3 93.9% · Q4 94.4% · 4Q avg 92.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.0% |
11.6%
1.6 pts better
|
12.0%
2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.0% · Observed 10.9% · Expected 12.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.4% |
2.4%
About the same
|
1.6%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 3.5% · Q3 2.8% · Q4 0.0% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.2% |
75.9%
15.3 pts better
|
79.7%
11.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.0% |
20.9%
6.1 pts worse
|
23.9%
3.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.0% · Observed 32.6% · Expected 28.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-21 · Fire 2023-12-21
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-01-24 · Fire 2023-01-24
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-13
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 2024-12-28
F · Potential for more than minimal harm
2024-11-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-28
F · Potential for more than minimal harm
2024-11-13
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-12-28
F · Potential for more than minimal harm
2024-11-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-12-28
F · Potential for more than minimal harm
2024-11-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-28
E · Potential for more than minimal harm
2024-11-13
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-12-28
E · Potential for more than minimal harm
2024-11-13
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-12-28
F · Potential for more than minimal harm
2023-12-21
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-02-02
E · Potential for more than minimal harm
2023-12-21
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 2024-02-02
E · Potential for more than minimal harm
2023-01-24
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 2023-03-09
E · Potential for more than minimal harm
2023-01-24
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 2023-03-09
E · Potential for more than minimal harm
2023-01-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-03-09
E · Potential for more than minimal harm
2023-01-24
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2023-03-09
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-11-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-28
F · Potential for more than minimal harm
2024-11-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-28
D · Potential for more than minimal harm
2024-11-13
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-12-28
D · Potential for more than minimal harm
2024-11-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-28
D · Potential for more than minimal harm
2024-11-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-28
D · Potential for more than minimal harm
2023-12-21
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-02-02
D · Potential for more than minimal harm
2023-12-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-02-02
D · Potential for more than minimal harm
2023-12-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-02
E · Potential for more than minimal harm
2023-01-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-01-24
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-01-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-01-24
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-01-24
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-03-10
Penalties and ownership
What sits behind the stars
Ownership
Ambassador Holding Company
5% Or Greater Direct Ownership Interest · Organization
Juilfs, Sally
5% Or Greater Indirect Ownership Interest · Individual
Juilfs, Timothy
5% Or Greater Indirect Ownership Interest · Individual
Juilfs, Tyler
5% Or Greater Indirect Ownership Interest · Individual
Barry, Sean
Operational/Managerial Control · Individual
Filliez, Brandy
Operational/Managerial Control · Individual
First National Bank Omaha
5% Or Greater Mortgage Interest · Organization
Juilfs, Sally
Corporate Director · Individual
Juilfs, Sally
Corporate Officer · Individual
Juilfs, Timothy
Corporate Director · Individual
Juilfs, Timothy
Corporate Officer · Individual
Juilfs, Tyler
Corporate Director · Individual
Juilfs, Tyler
Corporate Officer · Individual
Lange, Michael
Operational/Managerial Control · Individual
Sattar, Arif
Operational/Managerial Control · Individual
Shanholtz, Brent
Operational/Managerial Control · Individual
Stoupa, Tyler
Operational/Managerial Control · Individual
The Ambassador Group Inc
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
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
#2
Holmes Lake Rehabilitation & Care Center
Lincoln, NE
1-star overall rating with 1-star inspections with $3,174 in total fines with 10 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#3
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
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