Greendale Park Nursing And Rehab
Greendale Park Nursing and Rehab in Greendale, WI — inspection on March 19, 2025.
Found 5 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.
Inspection Findings
lunch. RD-M went back after lunch and R2 felt much better. RD-M stated R2 did not say R2 had any
did not have any further concerns, so RD-M thought maybe R2 just needed to eat something.
On 3/19/2025, at 10:14 AM, Surveyor interviewed MT-N who stated R2 did have complaints of nausea on 3/13/2025 on day shift and MT-N notified the NP who went into assess R2. MT-N stated that the NP ordered something for nausea and abdominal cramping. MT-N could not recall if R2 had complaints of a headache or not, but just remembers the nausea. MT-N stated that R2 did not complain of any more nausea the rest of the day. MT-N was not aware of any concerns with R2 having diarrhea or constipation. MT-N stated nothing got passed on in shift report that MT-N can recall.
On 3/19/2025, at 11:30 AM, CNO-C stated that the orders were looked at for R2's readmission from 3/14/2025 and fixed. CNO-C stated that no bowel assessments could be located for R2 prior to 3/10/2025.
On 3/19/2025, at 12:30 PM, Surveyor shared concerns with NHA-A and CNO-C that R2 did not have a care plan initiated for risks of constipation and history of diverticulosis with monitoring and interventions, R2 did not have consistent documentation or monitoring of R2's bowel elimination or that R2's nausea/ diarrhea was not addressed on 3/12/2025 and R2 went to the hospital with abdominal cramping on 3/13/2025 with diagnoses of moderate colonic stool burden with mildly distended rectal vault, correlate for constipation.
Surveyor also had concern that R2's orders from readmission from the hospital on 3/14/2025 were not addressed to prevent further constipation issues. CNO-C stated that a bowel monitoring policy and procedure could not be located, but it does exist and will email Surveyor the bowel monitoring policy.
At the time of this write up, Surveyor has not received an email with the bowel monitoring policy and procedure.
525549 03/19/2025
Greendale Park Nursing and Rehab 5404 W Loomis Rd Greendale, WI 53129
According to the NPIAP (National Pressure Injury Advisory Panel) staging system, the pressure ulcer is classified as stage 3.
Additional factors that contribute to non-healing include bed-bound status, bowel incontinence and bladder incontinence.
Provider Comments document Prognosis: Guarded, dependent on offloading and moisture management.
Discussed pressure relief and redistribution strategies.
Patient is on an appropriate support surface for the patient to use when supine and should be on a weight shifting schedule and skin care/continence schedule per facility protocol.
The balance of moisture is critical to wound healing. I have given caregivers instructions about managing skin moisture which include using a skin barrier and wicking agent.
Patient wears an adult brief.
Consider Foley catheter in future if urine management becomes a problem.
R3 did not have an incontinence care plan implemented (Cross reference F-F690).
On 3/18/25 at 9:00 AM, Surveyor met with Acting Director of Nursing (DON)-C to discuss concerns: R3 admitted to the facility with pressure injuries and MASD to her coccyx.
Treatment was not implemented until 5 days later, after R3 was seen by the wound physician. At this time a stage 3 pressure injury was identified on her coccyx which required mechanical debridement of necrotic tissue and slough. R3 was readmitted following hospitalization on 2/5/25.
The facility did not complete a comprehensive assessment and measurements of R3's wounds and no treatments were implemented until 2 days later, which included only barrier cream and not the previously ordered (appropriate) treatment for stage 3 pressure injury. 5 days later, the wound physician documented R3's coccyx stage 3 pressure injury declined/was larger in size and required mechanical debridement of necrotic tissue and slough.
Acting DON-C reported she will review information and see if there is any additional information to provide. No additional information was provided prior to survey exit.
On 3/19/25 at 12:30 PM, Nursing Home Administrator (NHA)-A, Acting DON-C, and DON-B were advised of the above concerns.
525549 03/19/2025
Greendale Park Nursing and Rehab 5404 W Loomis Rd Greendale, WI 53129
about managing skin moisture which include using a skin barrier and wicking agent.
Patient wears an
On 3/19/25 at 11:02 AM, Surveyor spoke with MDS-O who reported it was her understanding that
On 3/18/25 at 9:00 AM, Surveyor met with Acting Director of Nursing (DON)-C to discuss concerns: R3 admitted to the facility with pressure injuries and MASD to her coccyx. R3 was identified to be always incontinent of bowel and bladder and dependent for toileting hygiene. A personalized care plan was not implemented to manage R3's incontinence and potential effect on her skin. R3's coccyx MASD progressed to a stage 3 pressure injury.
Acting DON-C reported she will review information and see if there is any additional information to provide. No additional information was provided prior to survey exit.
On 3/19/25 at 12:30 PM, Nursing Home Administrator (NHA)-A, Acting DON-C, and DON-B were advised of the above concerns.
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
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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.