Adept Nursing Gretna: Hand Hygiene Violations - NE
On August 20, inspectors watched nursing assistant NA-D clean Resident 4 after a bowel movement, apply a new brief, put on the resident's socks, and change a urinary catheter drainage bag to a leg bag. Throughout this 25-minute morning routine, NA-D never washed hands between removing old gloves and putting on new ones.
The resident required enhanced barrier precautions due to wounds and the urinary catheter. Yet NA-D never wore a protective gown during any of the intimate care, despite facility protocols.
NA-E assisted with the care routine and made similar hand hygiene mistakes. After removing a soiled bed pad and placing it in a trash bag, NA-E removed gloves, immediately put on new gloves without washing hands, then helped position a lift sling under the resident. NA-E later removed those gloves and left the room to get a Hoyer lift, again without hand washing.
Both assistants washed their hands properly at the start of their shift. NA-D scrubbed for 35 seconds with soap and water. NA-E washed for 28 seconds. But neither performed hand hygiene again during the extended care session.
When questioned after the observation, both nursing assistants admitted they should have washed their hands between glove changes. NA-E told inspectors at 10:25 AM that hand hygiene was not performed between glove changes "and should have been." NA-D gave the same acknowledgment during a 12:29 PM interview.
The facility's own Hand Hygiene policy, revised as recently as May 31, 2024, explicitly addresses this requirement. The policy states: "The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves."
Neither assistant understood the enhanced barrier precautions required for Resident 4. When inspectors interviewed NA-E at 10:23 AM, the assistant revealed being "not aware of the need to utilize EBP when providing high contact cares with Resident 4." NA-D expressed identical ignorance during the afternoon interview.
The Director of Nursing confirmed that Resident 4 was indeed supposed to be in enhanced barrier precautions for both wound care and urinary catheter management. However, the DON couldn't explain what a letter B marking at the bottom of the resident's care sign meant, suggesting communication gaps about infection control protocols.
Enhanced barrier precautions typically require gowns, gloves, and strict hand hygiene protocols to prevent transmission of infectious organisms. The resident's wounds and indwelling catheter created multiple pathways for potential infection.
The inspection revealed a pattern of staff unfamiliarity with basic infection control requirements. Two different nursing assistants providing direct care to the same high-risk resident both demonstrated identical knowledge gaps about enhanced precautions and hand hygiene protocols.
Federal regulations require nursing homes to maintain infection prevention and control programs. Hand hygiene represents the most fundamental infection control measure, particularly crucial when staff move between different body sites during intimate care.
The facility's policy acknowledged that gloves alone provide insufficient protection. Cross-contamination can occur when staff touch contaminated glove surfaces while removing them, then immediately handle clean supplies or touch the resident's skin with new gloves.
During the observed care routine, NA-D moved from cleaning fecal matter to applying clean clothing and handling catheter equipment without hand washing. NA-E handled soiled linens and trash before touching clean lift equipment and the resident's body.
The violations occurred during routine morning care that residents receive daily. Similar hand hygiene lapses could affect multiple residents throughout the facility if staff lack proper training or oversight.
Resident 4's care involved multiple high-risk activities: perineal cleaning after bowel movements, brief changes, catheter manipulation, and full-body repositioning with mechanical lift equipment. Each activity transition represented an opportunity for bacterial transmission without proper hand hygiene.
The inspection found that frontline nursing staff remained unaware of enhanced barrier protocols six months after the facility updated its hand hygiene policy. The Director of Nursing's uncertainty about infection control signage suggested supervisory knowledge gaps as well.
Both nursing assistants ultimately acknowledged their mistakes when confronted with specific observations. But their initial ignorance of enhanced barrier requirements and hand hygiene protocols indicated systemic training deficiencies rather than isolated oversights.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Adept Nursing & Rehab of Gretna from 2025-08-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Adept Nursing & Rehab of Gretna in Gretna, NE was cited for violations during a health inspection on August 21, 2025.
Throughout this 25-minute morning routine, NA-D never washed hands between removing old gloves and putting on new ones.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.