Greendale Park Nursing: Illegal Discharge Without Notice - WI
The resident, identified in the inspection report only as R1, had a tracheostomy. At some point during her stay at Greendale Park Nursing and Rehab, she was transferred to a hospital. What happened next is documented in the hospital's own records, which a federal surveyor obtained after the facility's admissions director insisted there was no documentation of the refusal at all.
There wasn't, the admissions director explained, because the referral specialist had probably shredded it.
A hospital social worker's progress note, dated during R1's hospitalization, describes reaching out to the facility's referral specialist in admissions to check on the status of a return placement. The specialist asked the social worker to re-fax the referral and said she would call back after reviewing the patient's information. A second note, dated two days later, records what happened next: the referral specialist left a voicemail. The facility was unable to accept the patient. The reason given: "Behavior issues or concerns."
The surveyor brought those hospital records to a meeting with the Director of Nursing and the Admissions Director on August 12. The Director of Nursing, identified as DON-B, offered several possible explanations for why R1 might have been turned away. Maybe the facility couldn't provide one-on-one assistance around the clock to keep R1 from pulling out her trach. Maybe R1 still had restraints. Maybe the facility had hit its limit of tracheostomy patients, which DON-B said was approximately ten.
On the day of the inspection, there were five trach residents in the building.
The surveyor asked DON-B whether a 30-day notice of discharge had been issued to R1 or her representative, and whether the facility had begun coordinating a safe transfer to another placement. DON-B said no. No notice had been given. No transfer coordination had begun. DON-B offered nothing further.
The Admissions Director, identified as Director-E, had told the surveyor earlier that morning that the referral specialist never documented any of her communications with the hospital in the facility's electronic health record. Asked whether any written documentation existed anywhere, Director-E said no. The referral specialist, Director-E explained, had probably shredded whatever she had. Director-E also said the facility would have taken R1 back if a bed had been available, and that a bed was held for R1 until a certain date before the hold expired.
The hospital's case manager told a different story. She reviewed the social worker's notes herself before speaking with the surveyor and confirmed that the social worker had attempted to arrange R1's return to the facility and was told the facility could not take her back.
The inspection was conducted as a complaint survey and completed August 12, 2025. CMS cited the facility under F0627, covering a resident's right to return to the facility following hospitalization. The deficiency was tagged at a level of minimal harm or potential for actual harm, affecting few residents.
R1's current placement is not documented in the inspection report.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Greendale Park Nursing and Rehab from 2025-08-12 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: July 5, 2026 · Our methodology
Greendale Park Nursing and Rehab in Greendale, WI was cited for violations during a health inspection on August 12, 2025.
The resident, identified in the inspection report only as R1, had a tracheostomy.
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.