Cycle 1
Health 2025-07-10 · Fire 2025-07-10
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Omaha, NE
Ambassador Health of Omaha
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1540 North 72ndStreet, Omaha, NE
(402) 393-6500
Overall
4 / 5
CMS overall stars
Health inspections
4 / 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
146
Certified beds
Average residents
82
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ambassador Health
Operator or chain grouping
Approved since
1993-01-29
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
2.13
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
2.83
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
1.79
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
6.75
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
4.96
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
6.13
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
1.80
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.96
CMS adjusted RN staffing hours
Adjusted total hours
3.05
CMS adjusted total nurse staffing hours
Case-mix index
3.02
Higher values indicate more complex resident acuity
RN turnover
19%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
26%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,406
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.30
Composite VBP score used to determine payment impact.
Payment multiplier
0.9898
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.77
Baseline 19.52% · Performance 20.15% · Measure score 2.77 · Achievement 2.77 · Improvement 0
Healthcare-associated infections
2.66
Baseline 6.94% · Performance 7.04% · Measure score 2.66 · Achievement 2.66 · Improvement 0
Total nurse turnover
9.10
Baseline 31.86% · Performance 26.50% · Measure score 9.10 · Achievement 9.10 · Improvement 7.15
Adjusted total nurse staffing
0
Baseline 3.06 hours · Performance 3.09 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.02% |
10.72%
1.7 pts better
|
No Different than the National Rate · Eligible stays 125 · Observed rate 5.6% · Lower 95% interval 6.4% |
| Discharge to community | 59.38% |
50.57%
8.8 pts better
|
Better than the National Rate · Eligible stays 132 · Observed rate 56.82% · Lower 95% interval 50.9% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 112 · Denominator 112 |
| Falls with major injury | 0.89% |
0.77%
0.1 pts worse
|
Numerator 1 · Denominator 112 |
| Discharge self-care score | 58.44% |
53.69%
4.8 pts better
|
Numerator 45 · Denominator 77 |
| Discharge mobility score | 57.14% |
50.94%
6.2 pts better
|
Numerator 44 · Denominator 77 |
| Pressure ulcers or injuries, new or worsened | 1.79% |
2.29%
0.5 pts better
|
Numerator 2 · Denominator 112 · Adjusted rate 1.82% |
| Healthcare-associated infections requiring hospitalization | 7.04% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 87 · Observed rate 5.75% · Lower 95% interval 3.97% |
| Staff COVID-19 vaccination coverage | 11.06% |
8.2%
2.9 pts better
|
Numerator 26 · Denominator 235 |
| Staff flu vaccination coverage | 36.44% |
42%
5.6 pts worse
|
Numerator 86 · Denominator 236 |
| Discharge function score | 49.35% |
56.45%
7.1 pts worse
|
Numerator 38 · Denominator 77 |
| Transfer of health information to provider | 86.54% |
95.95%
9.4 pts worse
|
Numerator 45 · Denominator 52 |
| Transfer of health information to patient | 93.18% |
96.28%
3.1 pts worse
|
Numerator 41 · Denominator 44 |
| Resident COVID-19 vaccinations up to date | 20.97% |
25.2%
4.2 pts worse
|
Numerator 13 · Denominator 62 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 69.9% |
92.8%
22.9 pts worse
|
93.4%
23.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 73.6% · Q2 68.6% · Q3 68.7% · Q4 68.7% · 4Q avg 69.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 86.6% |
96.1%
9.5 pts worse
|
95.5%
8.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 86.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.2% |
4.5%
2.3 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.9% · Q3 1.5% · Q4 1.5% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.2% |
4.4%
3.2 pts better
|
11.4%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 1.8% · Q4 1.7% · 4Q avg 1.2% |
| Percentage of long-stay residents who lose too much weight | 0.7% |
5.3%
4.6 pts better
|
5.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 0.0% · Q4 1.5% · 4Q avg 0.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 37.4% |
19.5%
17.9 pts worse
|
19.6%
17.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.2% · Q2 36.8% · Q3 38.8% · Q4 38.8% · 4Q avg 37.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.0% |
21.6%
5.6 pts better
|
16.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 17.8% · Q3 17.0% · Q4 16.3% · 4Q avg 16.0% · 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 | 10.6% |
20.4%
9.8 pts better
|
16.3%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.4% |
19.9%
3.5 pts better
|
14.9%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · 4Q avg 16.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.6%
1.6 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.1% |
2.9%
2.2 pts worse
|
1.7%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 7.2% · Q3 7.5% · Q4 1.5% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 0.6% |
26.6%
26 pts better
|
19.8%
19.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents with pressure ulcers | 0.7% |
4.3%
3.6 pts better
|
5.1%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 0.9% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.6% |
80.5%
4.1 pts better
|
81.7%
2.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 85.5% · Q2 80.2% · Q3 82.1% · Q4 90.0% · 4Q avg 84.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.0% |
11.6%
0.4 pts worse
|
12.0%
About the same
|
Short Stay · 20240701-20250630 · Adjusted 12.0% · Observed 11.8% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.4%
2.4 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 72.0% |
75.9%
3.9 pts worse
|
79.7%
7.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 72.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.1% |
20.9%
8.2 pts worse
|
23.9%
5.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.1% · Observed 28.2% · Expected 23.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-14 · Fire 2024-05-14
2 health deficiencies
Top issue: Infection Control (1 deficiency)
7 fire-safety deficiencies
Top issue: Miscellaneous (3 deficiencies)
Cycle 3
Health 2023-04-20 · Fire 2023-04-20
0 health deficiencies
No concentrated health issue counts in this cycle.
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-10
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-08-31
E · Potential for more than minimal harm
2025-07-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-08-31
E · Potential for more than minimal harm
2025-07-10
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-08-31
F · Potential for more than minimal harm
2024-05-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-21
E · Potential for more than minimal harm
2024-05-14
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-06-21
E · Potential for more than minimal harm
2024-05-14
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-06-21
E · Potential for more than minimal harm
2024-05-14
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-06-21
E · Potential for more than minimal harm
2024-05-14
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-06-21
E · Potential for more than minimal harm
2024-05-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-21
E · Potential for more than minimal harm
2024-05-14
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2024-06-21
F · Potential for more than minimal harm
2023-04-20
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-05-31
F · Potential for more than minimal harm
2023-04-20
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-05-31
F · Potential for more than minimal harm
2023-04-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-31
F · Potential for more than minimal harm
2023-04-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-31
E · Potential for more than minimal harm
2023-04-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-31
E · Potential for more than minimal harm
2023-04-20
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-05-31
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-10
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 2025-08-22
D · Potential for more than minimal harm
2025-07-10
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-07-10
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-08-22
D · Potential for more than minimal harm
2024-05-14
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-21
Penalties and ownership
What sits behind the stars
Ownership
Ambassador Holding Company
5% Or Greater Direct Ownership Interest · Organization
Juilfs, Timothy
5% Or Greater Indirect Ownership Interest · Individual
Juilfs, Tyler
5% Or Greater Indirect Ownership Interest · Individual
Bleach, Jake
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
Rhoads, Eli
Operational/Managerial Control · Individual
Shanholtz, Brent
Operational/Managerial Control · Individual
Shehan, John
Operational/Managerial Control · Individual
Stern, Polly
Operational/Managerial Control · Individual
The Ambassador Group Inc
Operational/Managerial Control · Organization
Wester, Rebecca
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
The Cypress at Midtown
Omaha, NE
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Douglas County Health Center
Omaha, NE
2-star overall rating with 1-star inspections with 16 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
St. Joseph Villa Nursing Center
Omaha, NE
1-star overall rating with 1-star inspections with $36,170 in total fines with 16 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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