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F0689
E

Failure to Maintain Safe Bathing Water Temperatures

Gretna, Nebraska Survey Completed on 08-21-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that bathing and showering water temperatures did not exceed 110 degrees Fahrenheit, as required to prevent potential accidents. Multiple records and logs reviewed showed that water temperatures in various bathhouses and tubs consistently ranged from 111.4 to 116.4 degrees Fahrenheit, exceeding the facility's stated maximum safe bathing temperature. Observations conducted with the Regional Lead Maintenance confirmed that water temperatures in both the 100-hall and 200-hall bathhouses were above the 110-degree threshold. The facility's policies referenced a safe water temperature range of 98.6 to 120 degrees Fahrenheit, but staff interviews confirmed that the maximum for bathing should be 110 degrees Fahrenheit, and this standard was not met. The Resident Listing Report indicated that out of 45 residents, 22 were cognitively impaired and bathed in the bathhouses where the elevated water temperatures were recorded. Staff interviews confirmed that these residents, due to cognitive impairment, would be particularly vulnerable to the effects of excessively hot water. The facility did not have a policy specific to bathing in a tub, and the maintenance staff was responsible for checking and logging water temperatures, which were found to be above the safe limit on multiple occasions.

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