Greendale Park Nursing: Care Plan Failure Worsened Wound - WI
The resident, identified in inspection records as R3, was admitted to the facility with pressure injuries and moisture-associated skin damage to her coccyx, a condition caused when skin breaks down from prolonged contact with urine or stool. She was documented as always incontinent of both bowel and bladder and fully dependent on staff for toileting hygiene. Those facts were known. What didn't follow from them was any personalized care plan to manage her incontinence or address what that moisture was doing to her skin.
By the time a federal surveyor arrived at the facility on March 18, 2025, R3's moisture-associated skin damage had progressed to a stage 3 pressure injury, meaning the wound had deepened through the full thickness of her skin.
Stage 3 pressure injuries reach into the tissue beneath the skin. They are painful, slow to heal, and carry serious infection risk, particularly in the coccyx region where contamination from incontinence is constant.
The Acting Director of Nursing, identified in the report as DON-C, met with the surveyor that morning. She acknowledged R3 had been admitted with pressure injuries and moisture-associated skin damage. She acknowledged the incontinence. She said she would review the information and see if there was anything additional to provide. No additional information was provided before the survey team left the building.
The facility's own records showed that someone had, at some point, documented skin care guidance: using a skin barrier, a wicking agent, an adult brief, with a note to consider a Foley catheter if urine management became a problem in the future. That guidance existed somewhere in R3's record. It was never turned into a care plan that nursing staff were responsible for following.
When the surveyor spoke with the MDS coordinator, identified as MDS-O, on the morning of March 19, the coordinator said it was her understanding that nursing was responsible for creating care plans related to identified problem areas. The problem area here, incontinence affecting a resident with existing skin breakdown, had been identified. The care plan had not been created.
On the afternoon of March 19, the Nursing Home Administrator, identified as NHA-A, was formally notified of the findings, along with Acting DON-C and a second director of nursing identified as DON-B.
The inspection cited the violation at a level of minimal harm or potential for actual harm, affecting few residents. That classification reflects the regulatory framework's language, not a description of what happened to R3. She came in wounded. She left, or remained, with a deeper wound.
Pressure injuries at the coccyx are among the most preventable complications in long-term care. The standard response to a resident who is always incontinent and already has skin breakdown in that area is immediate, documented, individualized planning: what products to use, how often to reposition, how to clean the skin after each incontinence episode, who is responsible for each step. That response did not happen here.
What did happen is that the guidance sat somewhere in the record, unimplemented, while the skin over R3's coccyx broke down further, layer by layer, until it reached the tissue beneath.
Greendale Park Nursing and Rehab is a nursing and rehabilitation facility in Greendale, Wisconsin. The inspection was conducted on March 18 and 19, 2025.
R3's wound, when surveyors documented it, was a stage 3. Before she arrived at the facility, it was not.
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: 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.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 4, 2026 · Our methodology
Greendale Park Nursing and Rehab in Greendale, WI was cited for violations during a health inspection on March 19, 2025.
She was documented as always incontinent of both bowel and bladder and fully dependent on staff for toileting hygiene.
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.