Greendale Park Nursing And Rehab

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

must be the internet, she gets more pills. LPN-C then dispensed into a medication cup one tablet Vitamin C 500 mg, one tablet Magnesium Oxide 400 mg, one tablet Atorvastatin Calcium 10 mg, one tablet Bumetanide 1 mg, one capsule Cephalexin 250 mg, one table Eliquis 5 mg, & one tablet Metoprolol Succinate ER (extended release) 50 mg. LPN-C cleansed the end of Glargine Solostar pen with an alcohol pad, attached needle, and dialed insulin to 5 units At 8:50 a.m., Surveyor verified the number of pills in Resident R7's medication cup with LPN-C. On 8/12/25 at 8:52 a.m., LPN-C placed gloves on and entered Resident R7's room.

LPN-C placed the medication cup on Resident R7's over bed table, cleansed the back of Resident R7's right upper arm and administered Resident R7's Glargine insulin. After LPN-C administered Resident R7's insulin, LPN-C removed her gloves, left Resident R7's room, and cleansed her hands. Surveyor observed LPN-C did not stay in Resident R7's room until Resident R7's took the medication and the medication was on Resident R7's overbed table when LPN-C left Resident R7's room.Surveyor reviewed Resident R7's medical record and was unable to locate a physician order or an assessment for Resident R7 to self-administer her medication.Surveyor reviewed Resident R7's care plans and noted the following care plans: Physical functioning deficit initiated 4/15/25, Pressure ulcer actual initiated 4/16/25, Advanced Directive initiated 4/15/25, At risk for alteration in psychosocial wellbeing initiated 4/17/25, Recreational activities initiated 4/18/25, Nutrition and Hydration initiated 4/18/25, Assistance in planning my next steps to be able to go home safely initiated 6/1/25, At risk for falls initiated 6/9/25, and Risk for altered fluid balance initiated 5/27/25. Surveyor was unable to locate a care plan for the self-administration of medication for Resident R7. On 8/12/25, at 10:42 a.m., Surveyor asked LPN-C if they have self-administration of medication assessments. LPN-C replied yes if

they are cognitive and want to do it. Surveyor asked LPN-C if Resident R7 has a self-administration of medication assessment. LPN-C reviewed Resident R7's medical record and stated no, not that I see. Surveyor asked LPN-C why

she left Resident R7's room prior to Resident R7 taking her medication. LPN-C informed Surveyor she wanted me to check about her medication.On 8/12/25, at 10:46 a.m., Surveyor asked Licensed Practical Nurse/Unit Manager (LPN/UM)-K if the facility has self-administration of medication assessments. LPN/UM-K informed Surveyor if a resident wants to self-administer their medication, they speak to the provider, do an assessment, update the doctor and the doctor gives an order as to whether the resident can self-administer. Surveyor asked LPN/UM-K if a resident doesn't have an assessment to self-administer their medication should the nurse stay with the resident and watch the resident take their medication. LPN/UM-K replied yes. Surveyor informed LPN/UM-K of the observation of LPN-M leaving Resident R7's medication and Surveyor could not find a self-administration assessment. LPN/UM-K informed Surveyor Resident R7 does not self-administer her medication that she is aware of.No additional information was provided.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Greendale Park Nursing and Rehab

5404 W Loomis Rd Greendale, WI 53129

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

referral specialist communication with facility and hospital coordination. Admissions Director-E stated, the referral specialist did not document in the EHR. Surveyor asked if there is any written documentation or other documents that charts communication and Admissions Director-E stated, no, there is not. Admissions Director-E stated the referral specialist probably shredded any documents she may have had. Admissions Director-E stated, if there was an open bed, the facility would have taken back Resident R1 at the time of discharge from hospital. Admissions Director-E stated a bed was held for Resident R1 until [DATE REDACTED] and then bed-hold expired.On [DATE REDACTED], at 8:04 AM, Surveyor spoke with case manager-G from hospital who stated, she reviewed the social workers notes from the hospital that show the social worker did attempt to make arrangements for Resident R1 to return to the facility but was told by facility Resident R1 could not return. Surveyor requested

the hospital notes created by the social worker.Resident R1's Hospital Progress Note dated [DATE REDACTED], at 11:49 AM, documents, in part .SW (Social Worker) is continuing to follow for placement. I contacted referral specialist

in admissions at [facility name] [phone number] to inquire about status of referral that SW peer re faxed earlier this week. Referral specialist requested that referral be re faxed again and will contact me after she has a chance to review pt's information.SW will follow.Resident R1's Hospital Progress Note dated [DATE REDACTED], at 2:08 AM, documents, in part . SW is continuing to follow for placement. I received a voice mail message from referral specialist in admissions at [facility name] informing me that the facility is unable to accept pt.[facility] declined, Behavior issues or concerns.On [DATE REDACTED], at 11:33 AM, Surveyor interviewed DON-B and Admissions Director-E. Surveyor notified DON-B and Admissions-E that Surveyor obtained hospital records documenting the facility's refusal to readmit Resident R1. DON-B stated the only reasons that could ever happen is if facility was unable to care for Resident R1 as she had behavior issues and facility could not provide one on one assistance 24/7 to assure Resident R1 was not pulling out trach or Resident R1 still had restraints, or facility could not take approximately more than 10 trach patients at a time. Surveyor notes, on [DATE REDACTED], there were only 5 trach residents residing at the facility. Surveyor asked DON-B if a 30-day notice of discharge was issued to Resident R1 and/or residents' representative and coordination of a safe transfer to another facility had begun. DON-B stated, no 30-day transfer notice was provided. Surveyor notified DON-B of the concern Resident R1 was not allowed to return to the facility following hospitalization and a 30-day notice of discharge was not issued. No additional information was provided.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Greendale Park Nursing and Rehab

5404 W Loomis Rd Greendale, WI 53129

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0628

days, but no bed hold and transfer notice is provided to residents or residents’ representatives upon each hospitalization. DON-B understood the concern.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Greendale Park Nursing and Rehab

5404 W Loomis Rd Greendale, WI 53129

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

right before supper. Surveyor asked CNA-O how she knows she's supposed to provide incontinence cares every two hours. CNA-O replied that's what we are taught in class every two hours or prn (as needed).

On 8/12/25, from 8:56 a.m., to 9:12 a.m., Surveyor observed morning cares for Resident R4 with CNA-I. At 9:14 a.m., after CNA-I completed Resident R4's cares, Surveyor asked CNA-I what cares she will provide to Resident R4 for the rest of the day. CNA-I informed Surveyor she will get Resident R4 in the chair, feed Resident R4 breakfast, will check if she's wet, if wet will Hoyer her back to bed. She will ask Resident R4 if she wants to rest in bed otherwise will get her up.

On 8/12/25, at 1:41 p.m., Surveyor met with Licensed Practical Nurse/Unit Manager (LPN/UM)-K & LPN/UM-L. Surveyor inquired who is responsible for resident care plans. Surveyor was informed the unit managers and kind of all department heads. Surveyor informed LPN/UM-K & LPN/UM-L Surveyor noted there is a physical function deficit care plan which has an intervention which documents requires total assist times two for toileting but was unable to locate a person center incontinence care plan for Resident R4 who is incontinent of urine and bowel. Surveyor asked who would have been responsible for developing this care plan. Surveyor was informed this would be nursing but LPN/UM-K & LPN/UM-L weren't in this role and wasn't sure if it was different with the different management. Surveyor asked if there should be an incontinence care plan. LPN/UM-L replied yes and explained she wasn't sure if it would specify the times, but they know staff does every two hours and as needed.

On 8/12/25, at 2:12 p.m., Surveyor asked Director of Nursing (DON)-B who would develop an incontinence care plan. DON-B informed Surveyor MDS & sometimes nursing manager. Surveyor asked how CNAs knows when to provide incontinence care to residents who are incontinent. DON-B informed Surveyor most residents are independent and use their call lights and for the residents who are not independent they check and change every two to three hours. Surveyor informed DON-B there is no incontinence care plan developed for Resident R4 who is incontinent of urine and bladder and the physical function deficit care plan for toileting only has an intervention which documents requires total assist times two for toileting. DON-B informed Surveyor they don't put time restrictions in care plans; they do frequent check and change.

Surveyor informed DON-B a person-centered care plan should have been developed for Resident R4.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Greendale Park Nursing and Rehab

5404 W Loomis Rd Greendale, WI 53129

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm

ordered. LPN/UM-K informed Surveyor should be primed 2 units every time. Surveyor informed LPN/UM-K of the observations during Resident R7's medication pass with LPN-M.Not priming Resident R7's Humalog insulin pen and not priming & administering Resident R7's Glargine's insulin pen which was not dated resulted in 2 medication errors for Resident R7.No additional information was provided.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Greendale Park Nursing and Rehab

5404 W Loomis Rd Greendale, WI 53129

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

ophthalmic ointment.2.) Resident R4 was originally admitted to the facility on [DATE REDACTED] with diagnoses which includes diabetes mellitus (high blood sugar), left ACA (anterior cerebral artery) stroke (an ischemic stroke that restricts blood flow to the right side of the brain), chronic respiratory failure (long term condition where the lungs cannot adequately exchange oxygen and carbon dioxide), hypokalemia (low potassium), and dementia (loss of cognitive function that interferes with a person's daily life & activities).Resident R4's after visit summary dated 12/10/24 under the medication list documents insulin regular 100 unit/ml (milliliters) injection Commonly known as Humulin R Inject 8 units under the skin in the morning and 8 units at noon and 8 units in the evening. Inject before meals. Indications: High blood sugar. Potassium & sodium phosphates 280-150-250 mg (milligrams) pack. Commonly known as PHOS-NAK. Administer 2 packets per tube in the morning and 2 packets before bedtime. Last taken: 2 packets on December 10, 2024 10:04 a.m. Resident R4's hospital discharge summary for date of discharge 12/10/24 under medication list for start taking these medications includes insulin regular 100 unit/ml injection Commonly known as Humulin R Instructions: Inject 8 units under the skin in the morning and 8 units at noon and 8 units in the evening. Inject before meals. Indications: High blood sugar. Potassium & sodium phosphates 280-160-250 mg pack Commonly known as PHOS-NAK. Instructions: Administer 2 packets per tube in the morning and 2 packets before bedtime.Surveyor reviewed Resident R4's physician orders including discontinued orders and was unable to locate

an order for Resident R4's Humulin R insulin or Potassium & sodium phosphates 280-150-250 mg when Resident R4 was admitted on [DATE REDACTED]. Surveyor also reviewed Resident R4's December 2024 MAR (medication administration record) and was unable to locate these medications listed on the MAR.Resident R4's nurses note dated 12/13/24 at 1822 (6:22 p.m.) written by Licensed Practical Nurse (LPN)-D documents new orders to send out patient. Resident R4 was admitted to the hospital on [DATE REDACTED].On 8/12/25, at 1:21 p.m., Surveyor met with Licensed Practical Nurse/Unit Manager (LPN/UM)-L and LPN/UM-K. Surveyor informed LPN/UM-L & LPN/UM-K Resident R4 was originally admitted to the facility on [DATE REDACTED]. Resident R4's hospital after visit summary and discharge summary for 12/10/24 both documents insulin regular 100 unit/ml (milliliters) injection Commonly known as Humulin R Inject 8 units under the skin in the morning and 8 units at noon and 8 units in the evening. Inject before meals. Potassium & sodium phosphates 280-160-250 mg pack with instructions to administer 2 packets per tube in the morning and 2 packets before bedtime. Surveyor informed LPN/UM-L and LPN/UM-K Surveyor was unable to locate these medications in Resident R4's physician orders & Resident R4's December 2024 MAR. LPN/UM-L informed Surveyor Resident R4 came in at 2:00 p.m. on 12/10/24. LPN/UM-L & LPN/UM-K reviewed Resident R4's medical record. Surveyor asked if they were able to locate where these medications from the hospital processed by facility staff. LPN/UM-L replied no. LPN/UM-K informed Surveyor they don't know.Surveyor noted from 12/10/24 until Resident R4 was discharged on 12/13/24 Resident R4 missed 8 doses of Humulin R and 6 doses of Potassium & sodium phosphates.No additional information was provided.

Event ID:

Facility ID:

If continuation sheet