The Ambassador Nebraska City, Inc

In the surveyor’s words

From the most serious findings on record at The Ambassador Nebraska City, Inc, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF689Oct 31, 2024

  Licensure Reference Number 175 NAC 12.006.09(I) Based on interview and record review, the facility failed to ensure evaluations were completed for 5 (Residents 7, 12, 15, 47, and 205) of 8 sampled residents to ensure the safe use of a power lift chair recliner (lift chair)(a motorized chair that reclines and lift upward to assist the resident to stand up) to prevent accidents. The facility census was 52. Findings are: A record review of the facility's undated Fall Policy revealed it was the policy of the facility to provide a safe and healthful living environment for all residents. Fall risk assessments were to be completed by nursing staff following a fall event. […]

• No harm, potential for more than minimal, isolatedF580Apr 14, 2026

  Based on interview and record review the facility failed to notify the practitioner of significant weight loss for 1 (Resident 12) of 1 resident. The facility staff identified a census of 47. Findings are:A.Record review of facility's Weight Recording Policy dated 10/2025 revealed the following; Policy Statement -It is the policy of this facility to routinely monitor weight of all residents/patients. Procedure 1. All residents/patients are weighed upon admission and monthly thereafter, at a minimum. The admit weight will be recorded on the admission assessment.2. More frequent weights (i.e., weekly, daily) will be obtained when need is determined by physician, nursing or dietician. Weights will be recorded in the Electronic Health Record (EHR).3. […]

• No harm, potential for more than minimal, isolatedF692Apr 14, 2026

  Based on interview and record review the facility failed to complete a nutritional assessment prevent significant weight loss for 1 (Resident 12) of 1 resident. The facility staff identified a census of 47. Findings are:A.Review of a Nutritional Assessment Policy dated 1-2-24 revealed the following: As part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident.Policy Interpretation and ImplementationThe dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk… […]

• No harm, potential for more than minimal, isolatedF609Mar 10, 2025

  Licensure reference: 175 NAC 12-006.02(H) Based on interview and record review, the facility failed to ensure an allegation of potential misappropriation of medication was reported for 2 [Resident 1 and 3] of 5 sampled residents. The facility had a total census of 46 residents. Findings are: A review of facility investigation dated 2/12/25 revealed an allegation that a nurse was requesting medication aides sign out prn [as needed] controlled medications and provide them to the nurse to administer to Residents 1 and 3 instead of having the Medication Aide administer the medication directly to the resident. […]

• No harm, potential for more than minimal, isolatedF610Mar 10, 2025

  Licensure reference: 175 NAC 12-006.02(H) Based on interview and record review, the facility failed to ensure a thorough investigation had completed regarding an allegation of potential misappropriation of medications from 1 [Resident 1] of 5 sampled residents. The facility had a total census of 46 residents. Findings are: A review of facility investigation dated 1/12/15 revealed an allegation that a nurse was requesting medication aides sign out prn [as needed] controlled medications and provide them to the nurse to administer to Residents 1 and 3 instead of having the Medication Aide administer the medication directly to the resident. […]