Heritage Square: Stage 3 Pressure Injury Neglect - WI
The woman, identified in inspection records as R3, arrived at the facility with existing pressure wounds and moisture-associated skin damage on her coccyx. Staff documented her condition but implemented no treatment for five days.
When a wound physician finally examined her, the injury had deteriorated into a stage 3 pressure ulcer requiring mechanical debridement — the surgical removal of dead tissue and infected material.
R3 was hospitalized for treatment. Upon her return to Heritage Square, the cycle repeated itself.
Staff again failed to complete a comprehensive wound assessment or take measurements of her injuries. For two days, they applied only barrier cream to a stage 3 pressure injury that required specialized wound care protocols.
Five days later, the wound physician documented that R3's coccyx injury had grown larger and again required mechanical debridement of necrotic tissue.
The resident suffers from severe hypoxic ischemic encephalopathy — brain damage from oxygen deprivation. She also has chronic respiratory failure, heart failure, and epilepsy. Medical records show she cannot recognize the need to urinate or defecate and requires total assistance with all personal care.
Federal inspectors found that Heritage Square's own policies required staff to screen for and manage incontinence complications, particularly skin breakdown in residents like R3 who are "always incontinent of bowel and bladder."
The facility's January 2025 policy manual explicitly states that staff must "identify individuals with complications of existing incontinence, or who are at risk for such complications (e.g., skin maceration or breakdown or perineal dermatitis)."
For residents with severe cognitive impairment who cannot communicate their needs, the policy mandates a "check and change strategy" involving regular monitoring and protective measures. The primary goals, according to the facility's own documentation, are "to maintain dignity and comfort level and to protect the skin."
R3's admission assessment clearly identified her as always incontinent and dependent for all toileting care. Staff noted she had existing pressure ulcers and moisture-associated skin damage. The Care Area Assessment flagged her as high risk for developing additional pressure ulcers, specifically noting "Always incontinent. Moisture Associated Skin Damage = Yes."
Despite this documentation, no incontinence management plan was implemented.
The inspection revealed a pattern of delayed care that directly contributed to R3's deteriorating condition. During her initial admission, treatment was postponed until a wound physician could evaluate her — a five-day delay that allowed preventable tissue death.
The same pattern emerged after her hospitalization and readmission. While medical records showed R3 had a stage 3 pressure injury requiring specialized treatment, staff provided only basic barrier cream for 48 hours before implementing appropriate wound care.
Stage 3 pressure injuries extend through the full thickness of skin and into underlying tissue. They require immediate, aggressive treatment to prevent further tissue death and potential life-threatening complications like sepsis.
When confronted with these findings on March 18, Acting Director of Nursing C told inspectors she would review the information and provide additional details. No additional information was provided before the survey concluded.
The following day, inspectors advised Nursing Home Administrator A, Acting Director of Nursing C, and Director of Nursing B of their findings regarding R3's care failures.
Federal inspectors cited Heritage Square for failing to provide appropriate treatment and services to prevent skin-related complications for incontinent residents. The violation carries a designation of "minimal harm or potential for actual harm" despite the documented tissue death and surgical interventions required.
R3's case illustrates the human cost of institutional neglect. A vulnerable resident with profound cognitive disabilities was left to deteriorate in conditions that the facility's own policies were designed to prevent.
The mechanical debridement procedures she endured — twice — involved the surgical removal of dead and infected tissue from wounds that proper incontinence care might have prevented from worsening.
Her brain damage leaves her unable to advocate for herself or communicate her discomfort. She depends entirely on staff to recognize her needs and provide basic human dignity through regular hygiene care and skin protection.
Instead, she received delayed treatment that allowed preventable suffering and tissue death.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 19, 2026 · Our methodology
Greendale Park Nursing and Rehab in Greendale, WI was cited for neglect violations during a health inspection on March 19, 2025.
The woman, identified in inspection records as R3, arrived at the facility with existing pressure wounds and moisture-associated skin damage on her coccyx.
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.