Greendale Park Nursing: Missed Insulin Doses - WI
The resident, identified in inspection records as R4, was admitted to Greendale Park Nursing and Rehab on December 10, 2024. She had been hospitalized and came back with an after-visit summary and a discharge summary, both of which listed two medications she was supposed to receive immediately: insulin, to manage her diabetes, and a potassium and sodium phosphate supplement. The insulin was prescribed at 8 units three times a day, before meals. The supplement was to be given twice daily.
Neither medication appeared in her physician orders at the facility. Neither appeared on her medication administration record for December 2024. Nobody entered the orders. Nobody gave her the medications.
R4 had been living with diabetes, a left-side stroke that had affected blood flow to the right side of her brain, chronic respiratory failure, low potassium, and dementia. She was not a resident whose medication needs were ambiguous or whose paperwork was sparse. The hospital had sent her back with a clear list.
She stayed at Greendale Park from December 10 until December 13, when a nurse's note logged at 6:22 p.m. recorded new orders to send her out. She was readmitted to the hospital that same day.
In the three days between her arrival and her return to the hospital, R4 missed eight doses of insulin and six doses of the potassium supplement.
When a state surveyor sat down with two unit managers at the facility on August 12, 2025, nearly eight months after R4 had been discharged, the answer they gave was not a detailed explanation of what went wrong. One of the managers, identified as LPN/UM-L, confirmed that R4 had arrived at 2:00 p.m. on December 10. Both managers reviewed her medical record alongside the surveyor. When the surveyor asked whether either of them could find where the hospital medications had been processed by facility staff, LPN/UM-L said no. LPN/UM-K said they didn't know.
That was the full extent of what the facility offered. No additional information was provided.
The failure here was not complicated. A hospital sends a patient home with discharge papers. Those papers list her medications. Someone at the receiving facility is supposed to read those papers, enter the orders, and make sure the medications get administered. At Greendale Park, that did not happen. The process broke down at the beginning and stayed broken for three days.
For a resident managing diabetes, missed insulin doses are not a minor administrative inconvenience. Blood sugar that goes unmanaged can rise to dangerous levels. For someone who already had a stroke, chronic respiratory failure, and dementia, the margin for additional medical crisis is not wide. The inspection report classified the violation as minimal harm or potential for actual harm, meaning inspectors could not establish that the missed doses caused a documented injury. What they could establish, without dispute from anyone at the facility, was that the doses were missed.
Fourteen of them, across three days, for a woman who came through the door with paperwork that said exactly what she needed.
The medication orders R4 arrived with were not buried in a lengthy chart or written in ambiguous clinical language. The after-visit summary listed the insulin with specific instructions: inject 8 units under the skin in the morning, 8 units at noon, 8 units in the evening, before meals. The potassium supplement was equally specific: 2 packets in the morning, 2 packets before bedtime. The hospital had done its part. The paperwork existed.
By December 13, R4 was back at the hospital.
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 inspection records as R4, was admitted to Greendale Park Nursing and Rehab on December 10, 2024.
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.