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Complaint Investigation

Adept Nursing & Rehab Of Gretna

August 21, 2025 · Gretna, NE · 700 Highway 6
Citations 4
CMS Rating 2/5
Beds 63
Provider ID 285146
Healthcare Facility
Adept Nursing & Rehab Of Gretna
Gretna, NE  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

Adept Nursing & Rehab of Gretna in Gretna, NE — inspection on August 21, 2025.

Found 4 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0686
Quality of Life and Care Deficiencies

including the desired pressure setting, continuous or intermittent therapy, and frequency of dressing

wound according to physician order. -e.

Select foam type or gauze appropriate to the size 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.

285146 08/21/2025

Adept Nursing & Rehab of Gretna 700 Highway 6 Gretna, NE 68028

prevent accidents.

1-009.04(D)(i)(1)Based on observation, interview, and record review, the facility failed to ensure

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.

285146 08/21/2025

Adept Nursing & Rehab of Gretna 700 Highway 6 Gretna, NE 68028

wash temp reached 102 degrees F and a rinse temp of 119 degrees F. At 7:55 AM, DA-B put the

as it should. DA-A confirmed DA-A forgets to look at temp gauge on the dishwasher. In an interview on

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.

285146 08/21/2025

Adept Nursing & Rehab of Gretna 700 Highway 6 Gretna, NE 68028

crossed the straps and secured the lift sling to the Hoyer lift, and transferred the resident to the

10:25 AM with the Director of Nursing (DON) confirmed Resident 4 was in EBP for wound and urinary

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.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Gretna, NE, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Adept Nursing & Rehab of Gretna or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.