Water temperatures at Adept Nursing & Rehab of Gretna reached as high as 116.4 degrees Fahrenheit in shower facilities used by residents with dementia and other cognitive impairments. Federal guidelines recommend keeping domestic water below 120 degrees, though the facility's own documentation acknowledged that 100 degrees is considered safe for bathing.
The Regional Lead Maintenance worker confirmed during an August 19 inspection that maximum bathing temperature should be 110 degrees. He then tested the water himself. The 100-hall bathhouse shower measured 116.4 degrees. The tub in the same area reached 115.7 degrees.
"The bath house's tubs and showers were not below that," he told inspectors.
Of the facility's 45 residents, 22 were marked as cognitively impaired on the August 20 resident listing report. The administrator confirmed these residents bathed in the bathhouses where inspectors found the elevated temperatures. Three residents often refused bathing assistance and washed themselves.
Temperature logs revealed the problem persisted for weeks before the inspection. On July 23, the 100-hall bathhouse reached 116.4 degrees. On July 30, it measured 115.2 degrees. By August 13, both bathhouses exceeded 115 degrees.
The facility's own policies contained contradictory temperature guidelines. The July 2025 Resident Showers policy stated water should be between 98.6 and 120 degrees. Staff could use a thermometer "if one was available" or test water on their wrists. The Safe Water Temperatures policy from the same month set the same range, despite federal burn prevention guidelines.
A separate document dated August 23 acknowledged the safety concern more directly. It stated that federal guidelines recommend keeping water below 120 degrees "although this can still cause burns if exposure reaches five minutes." The document noted 100 degrees as safe for bathing.
Maintenance staff were supposed to check water heater controls and tap temperatures weekly. The logs show they documented the elevated temperatures but took no apparent action to reduce them. On August 19, when inspectors arrived, the 100-hall shower measured 116.2 degrees, the 200-hall shower reached 115.7 degrees, and the 100-hall tub was 115.9 degrees.
The Regional Director of Operations confirmed during an August 20 interview that safe bathing temperatures should be below 110 degrees. The director also acknowledged the facility lacked a specific policy for tub bathing.
Cognitively impaired residents face particular vulnerability to scalding injuries. They may not recognize dangerous water temperatures or communicate discomfort effectively. Some may be unable to adjust water temperature or exit a bathing situation quickly if burns begin.
The facility's testing procedures appeared inadequate for preventing accidents. Staff were instructed to test water on their wrists rather than use thermometers consistently. The wrist test, while common, is less precise than thermometer readings and may not detect temperatures that could harm sensitive skin over several minutes of exposure.
Temperature readings fluctuated throughout the documented period but remained consistently above recommended bathing levels. The lowest recorded temperature was 109.6 degrees on July 22, still nearly 10 degrees above the acknowledged safe bathing temperature.
The inspection occurred following a complaint, though the report does not specify whether the complaint involved water temperature or other safety concerns. Federal inspectors classified the violation as having potential for minimal harm affecting some residents.
Maintenance logs showed staff documented the problem but failed to correct it. Between July 21 and August 19, every recorded temperature measurement exceeded 110 degrees. The highest reading, 116.4 degrees, occurred multiple times in the 100-hall bathhouse shower.
The administrator confirmed that cognitively impaired residents used these facilities regularly. With nearly half the facility's population affected by cognitive impairment, the elevated water temperatures created ongoing burn risks for the most vulnerable residents.
Water temperature violations in nursing homes have led to serious injuries nationwide. Burns from hot water can cause permanent scarring and require extensive medical treatment, particularly among elderly residents with thin skin and slower reflexes.
The facility's own documentation revealed awareness of federal burn prevention guidelines while simultaneously maintaining water temperatures that exceeded safe levels for weeks. Staff continued using the bathhouses with elevated temperatures while recording the dangerous readings in official logs.
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.
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