The violation centered on negative pressure wound therapy, an advanced treatment that uses controlled suction to accelerate healing. Staff failed to trim black foam to match the wound's size and shape before placing it in the patient's injury.
Advanced Practice Registered Nurse-G confirmed during a telephone interview on August 20 that the black foam should be "trimmed to the size and shape of the wound and placed gently in the wound." The nurse revealed the wound had the potential to deteriorate if staff continued the improper application.
The facility's own policy, revised in August 2024, explicitly requires staff to "select foam type or gauze appropriate to the size and characteristics of the wound, and place gently into the wound." The policy mandates filling "the entire wound base and sides, tunnels, and undermined areas" with properly sized materials.
Negative pressure wound therapy represents a sophisticated treatment approach that facility administrators promoted as evidence-based care. The facility policy states the therapy "uses controlled sub-atmospheric (negative) pressure to assist and accelerate wound healing" and includes "an evacuation tube and a computerized pump that applies the negative pressure."
The policy outlines detailed application procedures. Staff must "carefully remove the existing wound dressing and discard" before cleansing "the wound according to physician order." The foam selection and placement step requires particular precision.
After placing the foam, staff must "apply the tubing to the dressing" and "seal the tubing assembly on top of the dressing" while ensuring "it will not lie on bony prominences." The policy requires physicians to be notified of any complications associated with the therapy.
The improper foam application violated multiple aspects of the facility's written procedures. Staff failed to match foam size to wound characteristics, potentially compromising the therapy's effectiveness and risking patient harm.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. The complaint investigation occurred on August 21, 2025, focusing specifically on wound care practices.
The facility operates under the name The Willows at Gretna, located on Highway 6 in the suburban community west of Omaha. Inspectors found no additional information available for review at the time of their survey exit.
Negative pressure wound therapy requires precise technique to achieve therapeutic benefits. When foam extends beyond wound boundaries or fails to conform to wound contours, the negative pressure system cannot function effectively. Improperly sized foam can also create pressure points that damage healthy tissue surrounding the wound.
The Advanced Practice Registered Nurse's warning about potential deterioration highlights the clinical significance of proper foam application. Wounds treated with incorrectly applied negative pressure therapy may heal more slowly, develop complications, or worsen despite the intended therapeutic intervention.
The facility's comprehensive policy demonstrates awareness of proper techniques, making the staff violation particularly concerning. The policy emphasizes evidence-based treatment and current standards of practice, yet staff failed to follow these established protocols during actual patient care.
The violation occurred despite clear written procedures requiring foam to match wound size and characteristics. Staff had access to detailed application steps, including specific instructions for foam placement and positioning requirements.
Federal regulations require nursing homes to provide wound care that meets professional standards and follows physician orders. The improper foam application potentially compromised both requirements, affecting the quality of care provided to the resident.
The complaint investigation suggests someone reported concerns about wound care practices at the facility. Federal inspectors respond to such complaints by examining specific allegations and determining whether violations occurred.
The timing of the policy revision, just months before the inspection, indicates recent attention to wound therapy procedures. However, the violation suggests staff training or implementation may have been inadequate despite updated written protocols.
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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