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Complaint Investigation

Greendale Park Nursing And Rehab

March 19, 2025 · Greendale, WI · 5404 W Loomis Rd
Citations 2
CMS Rating 1/5
Beds 105
Provider ID 525549
Healthcare Facility
Greendale Park Nursing And Rehab
Greendale, WI  ·  View full profile →
Inspection Summary

Greendale Park Nursing and Rehab in Greendale, WI — inspection on March 19, 2025.

Found 2 citations. 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.

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Inspection Findings

FF686
Minimal harm or According to the NPIAP (National Pressure Injury Advisory Panel) staging system, the pressure ulcer is Few offloading and moisture management. Discussed pressure relief and redistribution strategies. Patient is on affected

F-F686).

R3's Kardex as of 3/18/25 documents: Skin integrity - Encourage staff to reposition me every 2-3 hours.

Air mattress setting checks.

Heel boots to bilateral heels.

Staff will provide heel boots at all times.

Toileting - I need total assist x 1 for toileting.

Surveyor noted although R3 is identified to be always incontinent of bowel and bladder and has a stage 3 pressure injury and MASD, R3's Kardex included no indication of how often R3 is to be checked and changed for incontinence.

On 3/17/25 Surveyor spoke with (name of medical group) Nurse Practitioner (NP)-F. NP-F reported R3 has a stage 3 pressure injury on her coccyx, which she was told was present on admission, and several partial thickness areas of MASD to bilateral buttocks.

Surveyor asked what she thought was the cause of the MASD. NP-F stated, probably combination of wetness from incontinence and shearing.

Surveyor asked if the facility implemented a check and change schedule related to incontinence. NP-F reported she did not know.

Surveyor asked if R3's MASD is a result of wetness from incontinence, would she expect routine or more frequent checking and changing for incontinence. NP-F stated. Of course. I'm sure they have a protocol for weight shifting and skin care incontinence protocol.

Surveyor asked if she has communicated the need for weight shifting and skin care/incontinence care. NP-F stated. I have, it would be in my notes.

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 03/19/2025

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

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

F-F690).

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 03/19/2025

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.


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