Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Ambassador Sidney Inc during CMS and state inspections, most recent first.
Staff failed to follow proper infection control practices during meal service by using the same pair of gloves to touch both food and non-food surfaces while preparing sandwiches for residents. This practice did not comply with the facility's policy requiring single-use gloves.
A resident with severe cognitive and physical impairments, including a history of stroke and a below-the-knee amputation, did not consistently receive required fall prevention interventions such as proper placement of a fall mat and wheelchair. Observations showed these interventions were not always in place as directed by the care plan, and staff interviews revealed inconsistent understanding and application of the interventions.
A resident with severe self-care deficits and impaired communication experienced increased secretions, coughing, and emesis over several days. Staff did not implement a standing PRN order for suctioning or consistently monitor and document vital signs during this period. Interviews revealed that LPNs and the DON were unaware of the suctioning order and did not follow the facility's respiratory protocol for monitoring respiratory symptoms.
Nursing staff documented completion of a wound care treatment for a resident with a pressure ulcer before the treatment was actually performed. Certified nurse aides provided peri care and changed the resident's brief without applying the prescribed barrier cream or notifying the nurse, and the LPN later confirmed the treatment had not been done at the time it was charted. Facility policy requires accurate and timely documentation, which was not followed.
Staff failed to follow proper hand hygiene and Enhanced Barrier Precautions during care for two residents, including one with a suprapubic catheter and another with a pressure ulcer. In both cases, staff did not perform hand hygiene between glove changes or after touching potentially contaminated surfaces, contrary to facility policy and expectations.
A resident with severe cognitive deficits and pressure wounds did not receive wound care treatments as ordered. Observations revealed that treatment patches on the coccyx were not changed as scheduled, and the sore on the right ankle was uncovered. The DON acknowledged the oversight and discrepancies in documentation.
A resident with severe cognitive deficits and a history of acute kidney injury and chronic UTIs was not provided adequate fluids or monitored for intake and output, despite having a urinary catheter. Observations showed a lack of fluids in the resident's room, and staff admitted to not providing thickened liquids due to concerns about the resident's ability to manage them. The facility's policy on fluid management was not followed, leading to the resident's hospitalization for acute kidney injury and a complicated UTI.
Inadequate Infection Control During Meal Service
Penalty
Summary
Staff failed to use adequate infection control practices during meal service, as observed during lunch meal preparation. A dietary aide donned gloves and then touched multiple surfaces, including a bread bag, bread slices, utensils, and a cheese container, without changing gloves between tasks. The same gloved hands were used to handle both food items and non-food contact surfaces, contrary to the facility's glove use policy, which requires gloves to be used only once and discarded after use. These actions occurred while preparing sandwiches for residents, with a reported facility census of 40 residents at the time.
Failure to Consistently Implement Fall Prevention Interventions
Penalty
Summary
A deficiency occurred when staff failed to follow fall prevention interventions for a resident with significant cognitive and physical impairments. The resident was dependent on staff for all activities of daily living, had a history of cerebrovascular accident, anxiety, a below-the-knee amputation, and was receiving hospice care. The resident's care plan and fall risk assessments identified specific interventions, including placing a fall mat next to the bed and ensuring the wheelchair was positioned and locked near the bed. However, multiple observations revealed that these interventions were not consistently implemented. The fall mat was sometimes folded against the wall or not placed correctly, and the wheelchair was not always positioned as required by the care plan. Interviews with staff indicated inconsistent knowledge and application of the resident's fall interventions, with some staff referencing care plans, binders, or posted notes for guidance. The Director of Nursing confirmed that staff were expected to follow the interventions outlined in the care plan. Despite these expectations, the facility did not have a policy specifically related to following the care plan, contributing to the failure to consistently implement fall prevention measures for the resident.
Failure to Provide PRN Suctioning and Monitor Vitals During Respiratory Distress
Penalty
Summary
Staff failed to implement necessary respiratory interventions for a resident with significant self-care deficits, including cerebral palsy, seizure disorder, and dysphagia, who was dependent on staff for all activities of daily living and had impaired communication. The resident experienced increased secretions, frequent coughing, emesis, and congestion over several days, as documented in nursing notes. Despite a standing PRN order for suctioning with a Yankauer for secretions the resident could not clear, there was no evidence that suctioning was performed or that staff were aware of the order. Additionally, staff did not consistently monitor or document vital signs during the period of increased respiratory symptoms, with only a single set of vitals reported to the physician and no follow-up vitals recorded for two days. Interviews with LPNs and the DON revealed a lack of awareness regarding the PRN suctioning order and uncertainty about the location of suctioning supplies. The DON acknowledged that the order had been in place since a previous sinus infection and that staff likely did not know it existed. The facility's respiratory protocol required monitoring of respiratory symptoms and vital signs, but this was not consistently followed during the resident's episode of increased secretions and respiratory distress.
Inaccurate Documentation of Wound Care Treatment
Penalty
Summary
Nursing staff failed to accurately document the timing of a wound treatment for one resident who was admitted following a traumatic subdural hemorrhage and presented with a pressure sore to the coccyx. The resident had a physician's order for Calmoseptine ointment to be applied three times daily to the sacral pressure ulcer. On the morning in question, certified nurse aides provided peri care and changed the resident's brief without applying the prescribed barrier cream or notifying the nurse to complete the treatment. The resident was then transferred to the dining room without the wound care being performed at the scheduled time. The Medication Administration Record/Treatment Administration Record (MAR/TAR) indicated that the wound treatment was documented as completed, with a note that it was charted late but done on time. However, when questioned, the LPN assigned to the resident confirmed that the morning treatment had not yet been performed at the time it was documented. The facility's policy requires accurate and thorough documentation of all care provided, including the correct date and time for each entry, which was not followed in this instance.
Failure to Implement Hand Hygiene and Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement proper infection prevention and control practices during resident care for two residents. In one instance, a resident with severe cognitive impairment, renal insufficiency, and an indwelling suprapubic catheter required Enhanced Barrier Precautions (EBP) and hand hygiene as part of their care plan. During observed care, a CNA performed hand hygiene and donned PPE at the start, but after removing gloves and donning new ones, did not perform hand hygiene between glove changes while assisting the resident with dressing, grooming, and hygiene tasks. Both the Director of Nursing and the Administrator confirmed that hand hygiene should have been performed between glove changes. In another case, a resident admitted after hospitalization for a traumatic subdural hemorrhage and with a Stage II pressure sore required EBP during care. During observed care, a CNA removed a soiled brief with gloved hands and, before changing gloves or performing hand hygiene, reached into her pocket to use a walkie talkie. The DON stated that gloves should have been changed and hand hygiene performed before touching personal items. Facility policies required single-use gloves and specified EBP for high-contact care activities, including wound care.
Failure to Provide Ordered Wound Care
Penalty
Summary
The facility failed to provide wound care treatments as ordered for a resident with pressure wounds on her coccyx and inner ankle. The resident, who had severe cognitive deficits and was totally dependent on staff for care, had treatment orders for her wounds that were not followed. During an observation, it was noted that the treatment patches on her coccyx were not changed as per the schedule, and the sore on her right ankle was not covered with a bandage as required by the treatment order. The resident's care plan indicated a potential for pressure ulcers due to her condition, which included limited range of motion and incontinence. Despite this, the facility did not adhere to the prescribed wound care protocols. The Director of Nursing acknowledged the oversight and noted discrepancies in the documentation of wound care treatments, indicating a lapse in following the facility's wound care policy.
Inadequate Fluid Management for Resident with Urinary Catheter
Penalty
Summary
The facility failed to provide adequate fluids and monitor the intake and output for a resident with a history of acute kidney injury and chronic urinary tract infections. The resident, who had severe cognitive deficits and was dependent on staff for toileting and showering, was admitted with a urinary indwelling catheter. Despite the care plan indicating the need to monitor and encourage fluid intake, observations showed that the resident often had no fluids available in his room, and his fluid intake was significantly below the required daily amount. The nursing notes and staff interviews revealed that the resident's fluid intake was not adequately monitored or encouraged. Staff members admitted to not providing thickened liquids in the resident's room, citing concerns that he might try to fill the glass with regular water. The resident expressed that he would like to have fluids in his room, and staff acknowledged that they often skipped his room during water passes. The Director of Nursing was unaware of the low intake and output averages, indicating a lack of oversight in monitoring the resident's fluid status. The facility's policy on intake and output, which mandates providing adequate fluids and monitoring based on the resident's condition, was not followed. The resident's average daily fluid intake was far below the normal range, and his urine output was also low, suggesting inadequate hydration. This deficiency in care contributed to the resident's hospitalization for acute kidney injury and complicated urinary tract infection, highlighting a significant lapse in the facility's responsibility to ensure proper hydration and monitoring for residents with specific medical needs.
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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 Sidney
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tabor Manor Care Center | 10.7 mi | — | 20 | 0 |
| Prestige Care Center Of Nebraska City | 11.7 mi | — | 13 | 0 |
| The Ambassador Nebraska City, Inc | 12.2 mi | — | 1 | 0 |
| Garden View Care Center | 13.9 mi | — | 45 | 2 |
| Accura Healthcare Of Shenandoah | 14.3 mi | — | 16 | 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 August 2026) and official state health department websites.