Greendale Park Nursing: Insulin Pen Errors Found - WI
The resident, identified in inspection records only as R7, received two types of insulin: Humalog, a fast-acting insulin, and Glargine, a long-acting insulin. Both are administered by pen injector, a device that must be primed before use to clear air from the needle and ensure the dose delivered is accurate. The nurse, identified as LPN-M, primed neither pen before administering them to R7.
The Glargine pen had a second problem. It had not been dated.
Insulin pens used on patients are supposed to be dated when first opened. Without a date, there is no way to know how long the pen has been in use or whether the insulin inside remains viable. LPN-M administered the undated Glargine pen anyway.
A surveyor watched it happen.
When the surveyor reported the observations to the facility's licensed practical nurse and unit manager, identified as LPN/UM-K, the response was direct: pens should be primed two units every time. That was the standard. LPN-M had not followed it. The facility provided no additional information beyond that acknowledgment.
CMS recorded two separate medication errors for R7 from that single pass. The level of harm was classified as minimal harm or potential for actual harm.
Insulin errors carry particular risk for residents with diabetes. Skipping the priming step on an insulin pen can result in an air bubble displacing part of the dose, meaning the resident receives less insulin than prescribed. Over time, or in a resident whose blood sugar is already difficult to control, that kind of dosing inconsistency can matter. An undated pen introduces a separate uncertainty: insulin that has been open too long can degrade, and a degraded dose may not work as expected.
None of that chain of consequences was documented as having occurred with R7. The inspection classified the harm level at the lower end of the scale. But the errors were real, they were observed directly, and they were not caught by the facility before a federal surveyor had to point them out.
The inspection was triggered by a complaint. CMS records list the facility's identification number as 525549. Greendale Park Nursing and Rehab is located at 5404 W Loomis Road in Greendale.
What the record does not show is whether R7's blood sugar was checked after the medication pass, whether anyone went back to verify the Glargine pen's history, or whether LPN-M had administered insulin to other residents the same way before a surveyor happened to be watching.
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: 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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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 26, 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 inspection records only as R7, received two types of insulin: Humalog, a fast-acting insulin, and Glargine, a long-acting insulin.
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.