Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Adept Nursing & Rehab of Gretna
Gretna, NE · 63 certified beds · Last Life Safety survey March 5, 2026
CMS Certification Number 285146 · first certified June 1994
Ownership
Operated by AVID HEALTHCARE GROUP · For profit - Corporation
- Ownership changed August 2, 2023 (change of ownership)to THE WILLOWS AT GRETNA from BCP GRETNA LLC
Position within NE
25 citations — more than 80% of the 180 certified nursing homes in NE. Compared within NE rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 5 citations; the earlier surveys in the window averaged 10. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens March 2027 — about 5 months from now. This facility’s last Life Safety survey was March 2026. Facilities in NE are typically surveyed 12–14 months after the last one (median 13), measured over 271 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
1 of the 25 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 25 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
How that compares
Compared with the median facility in NE, and nationally. Surveyors differ markedly between states, so the NE figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 25 |
| Median facility in NE | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| August 15, 2023 | 17 |
| October 16, 2024 | 3 |
| March 5, 2026 | 5 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0712 | Have simulated fire drills held at unexpected times. | 3 | 2026-03-05 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 3 | 2026-03-05 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2026-03-05 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2024-10-16 |
| K-0500 | Meet other general requirements that are deficient. | 1 | 2023-08-15 |
| K-0919 | Meet requirements for the use of electrical equipment. | 1 | 2023-08-15 |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 1 | 2023-08-15 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 1 | 2023-08-15 |
What the citations cover
- Smoke Deficiencies 7
- Gas, Vacuum, and Electrical Systems Deficiencies 7
- Miscellaneous Deficiencies 6
- Egress Deficiencies 2
- Other 3
| Category | Citations |
|---|---|
| Smoke Deficiencies | 7 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 7 |
| Miscellaneous Deficiencies | 6 |
| Egress Deficiencies | 2 |
| Services Deficiencies | 2 |
| Emergency Preparedness Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
March 5, 2026 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (March 30, 2026) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (March 30, 2026) |
| K-0753 | Have restrictions on the use of highly flammable decorations. | Deficient, Provider has date of correction (March 30, 2026) |
| K-0781 | Have restrictions on the use of portable space heaters. | Deficient, Provider has date of correction (March 30, 2026) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (March 30, 2026) |
October 16, 2024 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (November 8, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (November 8, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (November 8, 2024) |
August 15, 2023 — 17 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (September 28, 2023) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (September 28, 2023) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (September 28, 2023) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (September 28, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (September 28, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (September 28, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (September 28, 2023) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (September 28, 2023) |
| K-0500 | Meet other general requirements that are deficient. | Deficient, Provider has date of correction (September 28, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (September 28, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (September 28, 2023) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (September 28, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (September 28, 2023) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (September 28, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (September 28, 2023) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (September 28, 2023) |
| K-0922 | Meet requirements for the use and maintenance of medical gas equipment. | Deficient, Provider has date of correction (September 28, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.