Adept Nursing & Rehab Of Gretna

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

size of the wound and placed in the wound.A telephone interview on 8/20/2025 at 12:45 PM with Advanced Practice Registered Nurse (APRN)-G, confirmed black foam should be trimmed to the size and shape of

the wound and placed gently in the wound. APRN-G revealed the wound had the potential to deteriorate if

the black foam was not trimmed to the size and shape of the wound.Record review of a facility policy entitled Negative Pressure Wound Therapy dated revised 8/2024 revealed: -To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. This policy addresses the use of negative pressure wound therapy (NPWT) for the treatment and management of wounds. - Negative pressure wound therapy is an active wound care treatment that uses controlled sub-atmospheric (negative) pressure to assist and accelerate wound healing. The therapy may be gauze based, foam based, or peel and stick, and includes

an evacuation tube and a computerized pump that applies the negative pressure. -1. Negative pressure wound therapy will be provided in accordance with physician orders, including the desired pressure setting, continuous or intermittent therapy, and frequency of dressing change. Clean technique shall be utilized unless otherwise specified by the physician. -8. General application process: -a. Carefully remove the existing wound dressing and discard. -b. Cleanse the wound according to physician order. -e. Select foam type or gauze appropriate to the size and characteristics of the wound, and place gently into the wound. -i.

Fill the entire wound base and sides, tunnels, and undermined areas. -g. Apply the tubing to the dressing. -ii. Using the attached tubing adhesive drape, or additional dressing drape, seal the tubing assembly on top of the dressing and ensure that it will not lie on bony prominences. -12. The physician shall be notified of any complications associated with the use of NPWT.There was no further information available for review at

the time of the survey exit.

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Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Willows at Gretna

700 Highway 6 Gretna, NE 68028

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Licensure Reference Number 175 NAC 12-006.09(I)Licensure Reference Number 175 NAC 1-009.04(D)(i)(1)Based on observation, interview, and record review, the facility failed to ensure bathing and showering water temperatures (temps) did not exceed 110 degrees Fahrenheit (F)(a temperature unite of measure) to prevent potential accidents. The facility census was 44.Findings are:A record review of the facility's Resident Showers policy with a date reviewed/revised of 7/2025 revealed the staff should help the resident sit on the shower chair, turn the shower on, the water temperature should be 98.6 degrees F to 120 degrees F. They could use a thermometer if one was available or test the water on the inside of the staff's wrist. A record review of the facility's Safe Water Temperatures policy with a date reviewed/revised of 7/2025 revealed water temperature should be set at no 98.6 degrees F to 120 degrees F or the state's allowable maximum water temperature. The Maintenance staff would check water heater temperature controls and the temps of tap water in all hot water circuits weekly and as needed.A record review of the facility's Testing and Logging Water Temperatures steps dated 08/23/2025 revealed For burn prevention, federal guidelines advise that you keep domestic water temperatures below 120 degrees Fahrenheit, although this can still cause burns if exposure reaches five minutes. Although 100 degrees Fahrenheit is considered a safe water temperature for bathing. On 08/19/2025 the bathhouse 100-hall shower was 116.2 degrees F, the 200-hall shower was 115.7 degrees F, and the 100-hall tub was 115.9 degrees F.A record

review of the facility's Task Name: Test and log the hot water temperatures log dated 08/13/2025 revealed bathhouse 200's temp was 115.7 degrees F and the bathhouse 100 was 115.6 degrees F.A record review of the facility's Task Name: Test and log the hot water temperatures log dated 07/21/2025 - 07/30/2025 revealed on 7/22/2025 bath house 200's temp was 109.6 degrees F and the bath house 100 was 115.3 degrees F. On 07/23/2025 bath house 200's temp was 113.4 degrees F, bath house 100's tub was 111.4 degrees F, and the bath house 100 was 116.4 degrees F. On 07/24/2025 bath house 200's temp was 111.6 degrees F, Bath house 100 tub was 113.4 degrees F, and the bath house 100 was 111.9 degrees F. On 07/30/2025 bath house 200's temp was 112.6 degrees F, Bath house 100's tub was 112.8 degrees F, and

the bath house 100 was 115.2 degrees F.A record review of the facility's Resident Listing Report dated 08/20/2025 revealed out of the 45 residents listed, 1 was in the hospital and 22 were marked as being cognitively impaired (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The report revealed 3 residents often refuse and self bathe.An observation on 08/19/2025 at 12:42 PM with the facility's Regional Lead Maintenance (RLM) revealed the RLM tested the 200-hall bath house sink, and the temperature was 115.5 degrees F. The RLN tested the 200-hall shower, and the temp was 113.7 degrees F. An observation on 08/19/2025 at 12:52 PM with the facility's RLM revealed the RLM tested the 100-hall bath house tub, and the temperature was 115.7 degrees F. The RLN tested the 100-hall bath house shower, and the temp was 116.4 degrees F. In an interview on 08/19/2025 at 3:34 PM, the RLM confirmed that the maximum bathing temperature should be 110 degrees F and the bath house's tubs and showers were not below that.In an interview on 08/20/2025 at 3:35 PM, the facility's Regional Director of Operations (RDO) confirmed the safe bathing temperatures was less 110 degrees F and the facility did not have a policy specific to bathing in a tub.In an interview on 08/21/2025 at 7:15 AM, facility's Administrator confirmed the Resident Listing Report dated 08/20/2025 that the Administrator provided revealed out of the 45 residents listed, 1 was in the hospital and 22 were marked as being cognitively impaired and confirmed those 22 residents bathed in the bath houses, however 3 residents often refuse and self bathe.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Willows at Gretna

700 Highway 6 Gretna, NE 68028

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

AM with the facility's Cook-A, that had been identified as the assistant dietary manager revealed DA-A ran

a load of 2 large bowls and 1 plate through the dishwasher. The was temp reached 98 degrees F and a rinse temp of 101 degrees F. At 7:45 AM DA-A ran a load of 11 plates and 2 bowls through the dishwasher and the wash temp reached 102 degrees F and a rinse temp of 119 degrees F. At 7:55 AM, DA-B put the dishes away in the kitchen.In an interview on 08/20/2025 at 7:47 AM, DA-A confirmed the thermometer on

the dishwasher was not working right and the machine used twice as much detergent as it should. DA-A confirmed DA-A forgets to look at temp gauge on the dishwasher. In an interview on 08/20/2025 at 10:05 AM, DA-A confirmed the dishes that were put away that morning were used for the lunch food preparation and service. In an interview on 08/20/2025 at 11:16 AM, the facility's Registered Dietician (RD) confirmed

the facility's dishwasher should have reached a minimum temperature of 120 degrees F during the wash and rinse cycles.In an interview on 08/20/2025 at 3:05 PM, The facility's Regional Director of Operations (RDO) confirmed the facility's dishwasher machine was an American Dish Service Model AF-3D. The RDO confirmed the dishwasher should have reached a minimum 120 degrees F during the wash and rinse cycles.In an interview on 08/20/2025 at 7:50 AM, Cook-A confirmed Cook-A observed the above temperatures on the dishwasher as DA-A ran the machine on 08/20/2025 at 7:41 AM and 7:45 AM. Cook-A confirmed the minimum wash and rinse temps should have been 120 degrees F and the machine did not reach that. In an interview on 08/21/2025 at 7:15 AM, the facility's Administrator confirmed all but 1 of the 44 residents that reside at the facility consume food from the kitchen.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Willows at Gretna

700 Highway 6 Gretna, NE 68028

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

gloves. Without donning a gown, NA-D assisted Resident 4 with perineal care in bed after a bowel movement and applied a new brief. Without donning a gown, NA-D changed Resident 4's urinary catheter drainage bag to a leg bag and assisted Resident 4 to roll side-to-side in bed to pull up a pair of slacks.

Without donning a gown, NA-D and NA-E placed the lift sling under Resident 4, crossed the straps and secured the lift sling to the Hoyer lift, and transferred the resident to the wheelchair.An interview on 8/20/2025 at 10:23 AM with NA-E revealed NA-E was not aware of the need to utilize EBP when providing high contact cares with Resident 4.An interview on 8/20/2025 at 10:25 AM with the Director of Nursing (DON) confirmed Resident 4 was in EBP for wound and urinary catheter. The DON was unsure of the reason for the letter B being marked at the bottom of the sign.An interview on 8/20/2025 at 12:29 PM with NA-D revealed NA-D was not aware of the need to utilize EBP when providing high contact cares with Resident 4. B. Record review of a facility policy entitled Hand Hygiene dated revised 5/31/2024 revealed: -6.

Additional considerations: -a. 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.Observation on 8/20/2025 from 9:55 AM through 10:20 AM of Resident 4's morning routine revealed NA-D washed hands with soap and water for 35 seconds and donned gloves. NA-E washed hands with soap and water for 28 seconds and donned gloves. NA-D provided perineal to Resident 4 after a bowel movement. Without changing gloves and without the benefit of hand hygiene, NA-D applied a new brief to Resident 4. Without changing gloves and without the benefit of hand hygiene, NA-D applied Resident 4's socks. NA-D doffed (removed) gloves, and without the benefit of hand hygiene donned new gloves and changed Resident 4's urinary drainage bag to a leg bag.NA-E removed a bed pad, retrieved a trash bag from the bottom of the trash receptacle, and placed the bed pad in the bag. NA-E doffed gloves, and without the benefit of hand hygiene, donned new gloves and obtained the lift transfer sling. With the assistance of NA-D, the lift sling was placed under Resident 4.NA-E doffed gloves and without the benefit of hand hygiene left the room to obtain the lift from its storage space.An interview on 8/20/2025 at 10:25 AM with NA-E confirmed hand hygiene was not performed between glove changes and should have been.An interview on 8/20/2025 at 12:29 PM with NA-D confirmed hand hygiene was not performed between glove changes and should have been.

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Facility ID:

If continuation sheet