Greendale Park: Missing Incontinence Care Plans - WI
The facility failed to develop individualized incontinence care plans for residents who require total assistance with toileting, instead relying on general two-hour check schedules that staff learned in training classes.
One resident, identified as R4, required total assistance from two staff members for toileting but had no person-centered incontinence care plan despite being incontinent of both urine and bowel. The resident's only care documentation was a physical function deficit plan noting the need for "total assist times two for toileting."
On August 12, inspectors observed morning care for R4 with a certified nursing assistant. After the aide completed the resident's care at 9:14 a.m., she told inspectors she would check throughout the day "if she's wet, if wet will Hoyer her back to bed."
When inspectors asked another nursing assistant how she knew to provide incontinence care every two hours, the aide replied "that's what we are taught in class every two hours or prn (as needed)."
The facility's Licensed Practical Nurses and Unit Managers acknowledged the missing care plan when confronted by inspectors. They confirmed that nursing staff should have developed an incontinence care plan but said they "weren't sure if it would specify the times."
One unit manager explained that "they know staff does every two hours and as needed" despite the absence of written protocols.
Director of Nursing B told inspectors that most residents use call lights when they need assistance, and for residents who cannot communicate their needs independently, "they check and change every two to three hours."
When informed that R4 lacked an incontinence care plan, the nursing director defended the facility's approach, saying "they don't put time restrictions in care plans; they do frequent check and change."
The nursing director initially told inspectors that the MDS coordinator and nursing manager typically develop incontinence care plans. But when pressed about R4's missing plan, she could not explain why one had never been created.
Federal regulations require nursing homes to develop comprehensive, person-centered care plans that address each resident's specific needs and preferences. For residents with incontinence, these plans should specify timing, methods, and individualized approaches to maintaining dignity and skin integrity.
The inspection found that nursing staff were making care decisions based on general training rather than individualized assessments. This approach fails to account for residents' varying needs, medical conditions, medications, or personal preferences that could affect incontinence care timing and methods.
R4's case illustrates the gap between policy and practice. Despite requiring maximum assistance and experiencing both urinary and bowel incontinence, the resident received care based on a nursing assistant's general training rather than a plan developed specifically for their condition and needs.
The facility's unit managers told inspectors they understood that incontinence care plans should exist but were uncertain about their specific requirements or timing protocols. This uncertainty among supervisory staff suggests systemic problems with care plan development and oversight.
When inspectors asked who was responsible for creating resident care plans, the unit managers said "the unit managers and kind of all department heads" but could not identify who should have developed R4's missing incontinence plan.
The nursing director's statement that the facility avoids "time restrictions" in care plans contradicts federal requirements for specific, measurable interventions. Person-centered care planning requires detailed protocols that staff can follow consistently, not general guidance to check residents periodically.
The violation was classified as causing minimal harm or potential for actual harm to few residents. However, inadequate incontinence care can lead to skin breakdown, infections, dignity violations, and other serious complications for vulnerable nursing home residents.
Federal inspectors completed their investigation on August 12, documenting the facility's failure to develop required care plans under regulation F 0656. The facility must submit a plan of correction addressing how it will ensure all residents receive individualized incontinence care planning going forward.
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: June 20, 2026 · Our methodology
Greendale Park Nursing and Rehab in Greendale, WI was cited for violations during a health inspection on August 12, 2025.
But when pressed about R4's missing plan, she could not explain why one had never been created.
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.