Greendale Park Nursing: Constipation Crisis Sent Resident to ER - WI
The March 2025 inspection of Greendale Park Nursing and Rehab, located at 5404 W. Loomis Road, found that the facility had failed to maintain consistent bowel monitoring for the resident, identified in inspection records as R2, failed to create a care plan addressing the resident's known constipation risks, and failed to act on warning signs that appeared in the days before hospitalization.
On March 12, 2025, a dietary staff member identified in the report as RD-M visited R2 before lunch and found the resident feeling nauseated. RD-M went back after the meal, found R2 feeling better, and never told nursing. The reasoning, as RD-M explained it to the inspector: R2 hadn't vomited, had improved after eating, and RD-M figured maybe R2 just needed food.
Nobody flagged the nausea. Nobody documented it.
The next day, March 13, a nurse identified as MT-N did report R2's nausea to a nurse practitioner, who came in, assessed the resident, and ordered medication for nausea and abdominal cramping. MT-N told the inspector that R2 settled down the rest of the shift and that nothing about the episode got passed along in shift report. MT-N said she wasn't aware of any concerns about diarrhea or constipation and couldn't recall whether R2 had complained of a headache.
R2 went to the hospital that same day. The diagnosis: moderate colonic stool burden with a mildly distended rectal vault, consistent with constipation.
When the inspector raised these concerns at 12:30 p.m. on March 19 with the nursing home administrator, identified as NHA-A, and the chief nursing officer, identified as CNO-C, the problems ran deeper than a single missed report. CNO-C acknowledged that no bowel assessments could be located for R2 before March 10. There was no care plan in place addressing R2's constipation risks or diverticulosis history, no consistent documentation of bowel elimination, and the orders written when R2 was readmitted from the hospital on March 14 had not been properly addressed to prevent the problem from recurring.
CNO-C also told the inspector that a bowel monitoring policy and procedure could not be located, then added that one does exist and offered to email it over.
At the time the inspection report was written, that email had not arrived.
The gap between what the facility said it had and what it could actually produce was a thread running through the entire finding. A policy that exists but cannot be found offers no protection to a resident whose nausea goes unreported because a dietary aide decided, without telling anyone, that food had solved the problem.
R2's history of diverticulosis, a condition that increases the risk of bowel complications, was known to the facility. The hospitalization was not a surprise that arrived without warning. The nausea on March 12 went unreported. The nausea on March 13 prompted medication but no shift handoff. The readmission orders went unaddressed. The care plan was never written.
The inspector rated the harm level as minimal or potential for actual harm, affecting a few residents. R2 came back from the hospital. The distended rectum and the stool burden were documented, diagnosed, and treated somewhere other than Greendale Park.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Greendale Park Nursing and Rehab from 2025-03-19 including all violations, facility responses, and corrective action plans.
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.
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Last verified: November 3, 2026 · Our methodology
Greendale Park Nursing and Rehab in Greendale, WI was cited for violations during a health inspection on March 19, 2025.
The March 2025 inspection of Greendale Park Nursing and Rehab, located at 5404 W.
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.