Greendale Park Nursing: Wound Care Failures Harm Resident - WI
That delay is at the center of a March 2025 federal inspection that found the facility caused actual harm to the resident, identified in inspection records as R3. By the time a wound physician finally examined her, the stage 3 pressure injury on her coccyx had progressed to the point where it required mechanical debridement — the physical removal of dead and dying tissue from the wound bed.
R3 had been admitted to Greendale Park with the coccyx wound already present. No comprehensive wound assessment was completed. No treatment was started. Five days passed.
When the wound physician did see her, the injury was classified as a stage 3 pressure injury, meaning it had broken through the skin into the tissue beneath. The physician debrided necrotic tissue and slough from the wound. A stage 3 injury that receives prompt, appropriate care does not always require debridement. This one did.
Then R3 was hospitalized. When she came back on February 5, 2025, the facility again failed to complete a full wound assessment. Two days passed before any treatment was started, and when it was, staff applied only barrier cream — not the wound treatment that had already been ordered for a stage 3 pressure injury. Five days after that, the wound physician returned and documented that the coccyx wound had declined. It was larger than before.
The nurse practitioner who took over R3's wound care on February 24 was direct about what the wound needed. In her progress note, NP-F wrote that R3's prognosis was guarded, dependent on offloading and moisture management. She noted that bowel and bladder incontinence were contributing to the wound's failure to heal. She documented that she had given caregivers instructions on managing skin moisture, including a skin barrier and wicking agent. She wrote that R3 should be on a weight-shifting schedule and a skin care and continence schedule per facility protocol.
When an inspector asked NP-F on March 17 whether the facility had actually implemented a check-and-change schedule for R3's incontinence, the nurse practitioner said she did not know. Asked whether she would expect more frequent incontinence checks given that moisture was driving the wound damage, NP-F said, "Of course. I'm sure they have a protocol for weight shifting and skin care incontinence protocol."
R3 did not have an incontinence care plan.
The moisture-associated skin damage to R3's bilateral buttocks, documented as MASD, was attributed by NP-F to a combination of wetness from incontinence and shearing. That damage was still present as of March 17, when the inspector visited. The coccyx wound by that point measured 1.4 by 0.9 by 0.1 centimeters, with granulation tissue forming and some nonviable material remaining. NP-F said she expected it to heal within a couple of weeks.
On the morning of March 18, the inspector sat down with the facility's acting Director of Nursing, identified as DON-C, and walked through the timeline: the five-day delay on admission, the incomplete assessment after rehospitalization, the two days before any treatment, the wrong treatment when it finally came, the wound that grew larger, the debridement. DON-C said she would review the information and see if there was anything additional to provide.
Nothing additional was provided before inspectors left.
The following afternoon, the nursing home administrator and two directors of nursing were formally notified of the findings. The inspection was completed March 19, 2025.
As of mid-March, R3's wounds were improving under the care of the outside medical group that had stepped in. The coccyx wound that arrived at Greendale Park in January, was left untreated, was treated incorrectly, and grew larger while in the facility's care, was finally, slowly, closing.
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.
R3 had been admitted to Greendale Park with the coccyx wound already present.
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.