Adept Nursing & Rehab Gretna: Hot Water Safety Failures - NE
Inspectors visited the facility on August 19, 2025. What they found in the bath houses serving the 100-hall and 200-hall wasn't a one-day anomaly or a broken thermostat discovered that morning. The temperature logs the facility had been keeping since at least late July told the story themselves.
On July 23, the 100-hall shower registered 116.4 degrees Fahrenheit. On July 24, the 100-hall tub was 113.4 degrees. On July 30, the 200-hall shower was 112.6 degrees and the 100-hall tub was 112.8 degrees. On August 13, the 200-hall bath house measured 115.7 degrees and the 100-hall measured 115.6 degrees. Every one of those readings was above the 110-degree maximum the facility's own regional maintenance lead would later confirm was the safe limit for bathing.
By the time inspectors arrived on August 19, nothing had changed. The regional lead maintenance staff member tested the 200-hall bath house sink with inspectors watching: 115.5 degrees. The 200-hall shower: 113.7 degrees. The 100-hall tub: 115.7 degrees. The 100-hall shower: 116.4 degrees.
That last number matters because of what the facility's own records say about water at that temperature. A testing and logging document dated August 23, 2025 noted that federal guidelines advise keeping domestic water below 120 degrees Fahrenheit, then added a qualification that undercuts any comfort that ceiling might offer: exposure at that temperature for five minutes can still cause burns. The document also noted that 100 degrees is considered a safe bathing temperature.
The showers were running at 116 degrees. Safe is 100. The gap between those two numbers is where residents were bathing.
Of the 45 residents listed in a facility report dated August 20, one was in the hospital. Of the remaining 44, 22 were marked as cognitively impaired, a category the report defined as covering problems with thinking, learning, memory, judgment, and decision-making. The administrator confirmed to inspectors that those 22 residents used the bath houses. Three residents who often refused bathing and self-bathed were noted separately.
Cognitive impairment matters here in a specific and practical way. A resident who cannot reliably process sensory information, communicate distress clearly, or make quick decisions about getting out of water that is burning them is not in the same position as someone who can. They may not recognize that the water is too hot. They may not be able to say so. They may not move away from it fast enough. The staff member bathing them is the last line of protection, and the temperature logs show that protection was not there.
The facility had two policies that addressed water temperature, both reviewed and revised in July 2025, the same month the logs show temperatures running over the limit. The Resident Showers policy said water should fall between 98.6 and 120 degrees and that staff could use a thermometer if one was available, or test the water on the inside of their wrist. The Safe Water Temperatures policy set the same range and said maintenance would check water heater controls and tap temperatures weekly.
The weekly checks were happening. The logs prove that. What the logs also prove is that readings above 110 degrees were recorded week after week and the temperatures were not brought down.
In the interview on August 19, the regional lead maintenance staff member confirmed that the maximum safe bathing temperature was 110 degrees Fahrenheit and confirmed that the tubs and showers were not below that threshold.
The regional director of operations, interviewed the following day, confirmed the same limit and added something else: the facility did not have a policy specific to bathing in a tub.
The facility's own policies permitted water up to 120 degrees. The regional maintenance lead said the safe limit was 110. The regional director of operations said the safe limit was less than 110. The logs showed temperatures hitting 116.4. Nobody had adjusted the water heater.
There is a version of this story where the temperature logs function as a safety system, where someone reviews the numbers, sees that they are too high, and fixes the problem before an inspector arrives. That is not what happened at Adept Nursing & Rehab of Gretna. The logs ran from late July through mid-August, reading after reading above the limit the facility's own staff acknowledged was the ceiling for safe bathing, and the water stayed hot.
The inspection was classified as a complaint survey, meaning someone had already raised a concern before inspectors walked through the door. The deficiency was cited at a level of minimal harm or potential for actual harm, the lower end of the harm scale. No resident was documented as having been burned.
What the record does not show is how many baths were given between July 22 and August 19, how many of the 22 cognitively impaired residents were bathed in water above 110 degrees, or whether any of them experienced discomfort they could not communicate to the staff washing them.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
Adept Nursing & Rehab of Gretna in Gretna, NE was cited for violations during a health inspection on August 21, 2025.
Inspectors visited the facility on August 19, 2025.
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.