Complaint Investigation

Greendale Park Nursing And Rehab

January 8, 2025 · Greendale, WI · 5404 W Loomis Rd

Citations 1

CMS Rating 1/5

Beds 105

Provider ID 525549

Healthcare Facility

Greendale Park Nursing And Rehab

Greendale, WI · View full profile →

Source Document

Official CMS Inspection Report (Medicare.gov) · 14 pages

Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.

Inspection Summary

Greendale Park Nursing and Rehab in Greendale, WI — inspection on January 8, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF700

old resident who was admitted to the facility on [DATE]. R8's diagnoses include muscle Few affected

F-F700).

The facility did not complete a thorough fall investigation, determine a root cause for his fall, complete reassessments to determine if bed rails continue to be appropriate for R8, and create a care plan with interventions in a timely manner.

Findings include:

The facility's Fall Risk Assessment that is not dated, documents:

Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls.

The facility utilizes a standardized risk assessment for determining fall risk.

The risk assessment categorizes residents as a high risk with a score of 10 or greater.

The risk assessment will be completed upon admission, quarterly, or when a significant change is identified.

Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk.

The nurse will initiate interventions on the resident's baseline care plan if the resident indicates high risk.

Each resident's risk factors, and environmental hazards will be evaluated when developing the residents comprehensive plan of care.

When any resident experiences a fall, the facility will:

Assess the resident.

Complete an event documentation report.

Complete a fall risk assessment.

Notify physician and family.

Review the residence care plan and update as indicated.

Document all assessments and actions.

525549

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 525549 B.

Wing 01/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Heritage Square Health Care Center 5404 W Loomis Rd Greendale, WI 53129

Frequently Asked Questions

What is an F-tag violation?

F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.

Were these violations corrected?

Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.

How often do nursing home inspections happen?

CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.

What should families do about these violations?

Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Greendale, WI, (5) Report new concerns to state authorities.

Where can I see the full inspection report?

Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Greendale Park Nursing and Rehab or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.

More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.