Ambassador Health of Lincoln

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11E Based on record review, observation, and interview, the facility failed to ensure kitchen staff wore hair restraints to contain all head and facial hair, failed to perform hand hygiene prior to food service and between contact with contaminated surfaces, failed to distribute beverages under sanitary conditions, and failed to have hair restrained during food distribution from the dining room in order to prevent the potential for food born illness for 69 of 83 residents that were served out of the kitchen. The facility census was 83.

Inspectors wroteThe facility failed to wear appropriate Personal Protective Equipment (PPE) during gastric-tube medication administration for Resident 24 and gastric-tube feeding for Resident 98; and the facility failed to ensure oxygen tubing was appropriately stored for Resident 47, nebulizer mask, chamber and tubing were cleaned and stored in a manner to prevent cross contamination for Resident 16 and Resident 77; and the facility failed to ensure the laundry cart was covered during delivery; and the facility failed to ensure clean water pitchers were provided. Nebraska Licensure Reference Number 175 NAC 12-006.18 and 175 NAC 1-005.06

Inspectors wroteLicensure Reference Number 175 NAC 12-007.04DBased on observation, record review, and interview, the facility failed to ensure that the ventilation systems were operational in 10 resident bathrooms (Rooms 113, 114, 115, 116, 117, 118, 119, 120, 121, and 122). The facility census was 83 at the time of survey.

Inspectors wroteLicensed Reference Number 175 NAC 12-006.06 Based on interviews and record review, the facility failed to provide prompt follow-up and communication regarding complaints and grievances brought to the Resident Council meetings. This had the potential to affect all residents residing in the facility at the time of the survey. The facility census was 83.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(vii)(2)Based on observation, record review, and interview, the facility failed to ensure activities were provided to meet the physical, mental, and psychosocial well-being for 3 (Residents 14, 47, and 66) out of 3 sampled residents. The facility census was 83 at the time of survey.

Inspectors wroteLicensed Reference Number 175 NAC 12-006.12(D)(i) Based on observations, interviews, and record review, the facility failed to ensure medications were stored and secured for three residents (Resident 10,16, and Resident 30), and to lock the medication cart while unattended. This had the potential to affect all residents residing in the facility at the time of the survey. The facility census was 83.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(F) Based on interviews and record reviews, the facility failed to honor the resident rights of one resident (Resident 1) by performing Cardiopulmonary resuscitation (CPR) when the resident was a Do Not Resuscitate (DNR), out of four residents sampled. The facility census was 87 at the time of the survey.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.02 (H) Based on interviews and record reviews, the facility failed to report an adverse event which involved violating resident rights of one resident (Resident 1) by performing Cardiopulmonary resuscitation (CPR) when the resident was a Do Not Resuscitate (DNR), out of four residents sampled. The facility census was 87 at the time of the survey.

Inspectors wroteLicensure reference number 175 NAC 12-006.11C Based on observation, interview and record review, the facility failed to perform hand hygiene and wear a beard net in the kitchen to prevent food-borne illness. And failed to ensure food items were sealed, labeled, and dated. This had the ability to affect 65 of 71 residents who eat out of the kitchen. The census of the facility was 72.

Inspectors wroteB. An observation on 11/12/24 at 7:11 AM revealed Medication Aide (MA)-G had been in the process of preparing medications for a resident when MA-G dropped a pill on the top of the medication cart then picked up the pill with ungloved hands and placed it into the medication cup containing other medications. When questioned of the facility process for dropped medications, MA-G confirmed that (gender) should not have picked the pill up with ungloved hands or picked the pill out of the medication cup which contained other pills, with ungloved hands and placed the pill into the sharps container (a safe, disposable container for needles, syringes, lancets, and often used as a safe container to dispose of medications). [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(S) Based on interview and record review, the facility failed to ensure the staff explained procedures and provide privacy during resident cares for 1 (Resident 15) of 3 sampled residents. The total facility census was 72.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(D) Based on observation, interview and record review, the facility failed to ensure the accuracy of the MDS (Minimum Data Set, a comprehensive assessment of each resident's physical and mental functional capabilities) related to the BiPap use for one (Resident 14) of two sampled residents. The facility identified a census of 72. Findings Are: A record review conducted on 11/7/24 of the face sheet printed on 6/6/24 revealed Resident 14 had been accepted into the facility on 1/24/24 with a primary diagnosis of COPD (a term for lung and airway diseases that restrict your breathing) and hypotension (a blood pressure that is lower than normal). [...]

Inspectors wroteLicensure reference number 175 NAC 12-006.09D6(7) Based on observation, interview and record review; the facility failed to follow the physician's order for administration of Oxygen for Resident 28.

Inspectors wroteLicensure Reference 175 NAC 12-006.09B1(2) Based on record review and interviews, the facility failed to ensure a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS- a comprehensive assessment of each resident's functional capabilities. An SCSA is required when a resident has a major improvement or decline in condition that will not resolve itself.) was completed after a significant change in condition for 1 (Resident 52) of 18 sampled residents. The facility census was 66.

Inspectors wroteLicensure Reference Number175 NAC 12-006.09B Based on record reviews and interviews, the facility failed to code anti-anxiety medication for Resident 50, and a fall for Resident 52 on the Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) . This affected 2 of 17 residents sampled. The facility census was 66.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.17D Based on observation, record review and interview; the facility failed to perform hand hygiene to prevent the spread of infection and prevent cross contamination during morning cares for 1 resident (Resident 34) of 1 sampled residents. The facility census was 66.