Greendale Park Nursing and Rehab

FElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Potential for more than minimal harm · Administration Deficiencies · Tag F0851 · Deficient, Provider has date of correction (Mar 2, 2026)

FProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Deficient, Provider has date of correction (Mar 2, 2026)

EEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0887 · Deficient, Provider has date of correction (Mar 2, 2026)

DAllow residents to self-administer drugs if determined clinically appropriate.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0554 · Deficient, Provider has date of correction (Mar 2, 2026)

DHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0584 · Deficient, Provider has date of correction (Mar 2, 2026)

DPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0605 · Deficient, Provider has date of correction (Mar 2, 2026)

DProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0628 · Deficient, Provider has date of correction (Mar 2, 2026)

DProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0688 · Deficient, Provider has date of correction (Mar 2, 2026)

DEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Deficient, Provider has date of correction (Mar 2, 2026)

DProvide safe, appropriate dialysis care/services for a resident who requires such services.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0698 · Deficient, Provider has date of correction (Mar 2, 2026)

DEnsure each resident must receive and the facility must provide necessary behavioral health care and services.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0740 · Deficient, Provider has date of correction (Mar 2, 2026)

DDevelop and implement policies and procedures for flu and pneumonia vaccinations.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0883 · Deficient, Provider has date of correction (Mar 2, 2026)

DTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 · Complaint inspection · Deficient, Provider has date of correction (Dec 4, 2025)

DRespond appropriately to all alleged violations.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0610 · Complaint inspection · Deficient, Provider has date of correction (Dec 4, 2025)

DEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0640 · Complaint inspection · Deficient, Provider has date of correction (Dec 4, 2025)

DEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0693 · Complaint inspection · Deficient, Provider has date of correction (Dec 4, 2025)

DAllow residents to self-administer drugs if determined clinically appropriate.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0554 · Complaint inspection · Deficient, Provider has date of correction (Sep 10, 2025)

DEnsure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0627 · Complaint inspection · Deficient, Provider has date of correction (Sep 10, 2025)

DProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0628 · Complaint inspection · Deficient, Provider has date of correction (Sep 10, 2025)

DDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0656 · Complaint inspection · Deficient, Provider has date of correction (Sep 10, 2025)

DEnsure medication error rates are not 5 percent or greater.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0759 · Complaint inspection · Deficient, Provider has date of correction (Sep 10, 2025)

DEnsure that residents are free from significant medication errors.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0760 · Complaint inspection · Deficient, Provider has date of correction (Sep 10, 2025)

DProvide appropriate treatment and care according to orders, resident’s preferences and goals.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0684 · Complaint inspection · Deficient, Provider has date of correction (Apr 11, 2025)

DProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0690 · Complaint inspection · Deficient, Provider has date of correction (Apr 11, 2025)

DEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Complaint inspection · Deficient, Provider has date of correction (Feb 13, 2025)

DTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0700 · Complaint inspection · Deficient, Provider has date of correction (Feb 13, 2025)

FHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0727 · Complaint inspection · Deficient, Provider has date of correction (Nov 7, 2024)

FConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Potential for more than minimal harm · Administration Deficiencies · Tag F0838 · Complaint inspection · Deficient, Provider has date of correction (Nov 7, 2024)

FProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Complaint inspection · Deficient, Provider has date of correction (Dec 13, 2024)

EEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0947 · Complaint inspection · Deficient, Provider has date of correction (Nov 7, 2024)

DHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0578 · Deficient, Provider has date of correction (Nov 7, 2024)

DProvide safe, appropriate dialysis care/services for a resident who requires such services.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0698 · Deficient, Provider has date of correction (Nov 7, 2024)

DTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0700 · Deficient, Provider has date of correction (Nov 7, 2024)

FEstablish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

Potential for more than minimal harm · Administration Deficiencies · Tag F0837 · Complaint inspection · Deficient, Provider has date of correction (Aug 6, 2024)

FConduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Potential for more than minimal harm · Administration Deficiencies · Tag F0944 · Complaint inspection · Deficient, Provider has date of correction (Aug 30, 2024)

DAllow residents to self-administer drugs if determined clinically appropriate.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0554 · Complaint inspection · Deficient, Provider has date of correction (Aug 30, 2024)

DEnsure residents have reasonable access to and privacy in their use of communication methods.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0576 · Complaint inspection · Deficient, Provider has date of correction (Aug 30, 2024)

DHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0585 · Complaint inspection · Deficient, Provider has date of correction (Aug 30, 2024)

DTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 · Complaint inspection · Deficient, Provider has date of correction (Aug 30, 2024)

DRespond appropriately to all alleged violations.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0610 · Complaint inspection · Deficient, Provider has date of correction (Aug 30, 2024)

DEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0676 · Complaint inspection · Deficient, Provider has date of correction (Aug 30, 2024)

DEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Complaint inspection · Deficient, Provider has date of correction (Aug 30, 2024)

DProvide safe and appropriate respiratory care for a resident when needed.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0695 · Complaint inspection · Deficient, Provider has date of correction (Aug 30, 2024)

DEnsure that residents are free from significant medication errors.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0760 · Complaint inspection · Deficient, Provider has date of correction (Aug 30, 2024)

DSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0842 · Complaint inspection · Deficient, Provider has date of correction (Aug 30, 2024)

DProvide appropriate treatment and care according to orders, resident’s preferences and goals.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0684 · Complaint inspection · Deficient, Provider has date of correction (May 3, 2024)

DEnsure each resident’s drug regimen must be free from unnecessary drugs.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0757 · Complaint inspection · Deficient, Provider has date of correction (May 3, 2024)

DDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0656 · Complaint inspection · Deficient, Provider has date of correction (Jan 31, 2024)

DProvide appropriate treatment and care according to orders, resident’s preferences and goals.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0684 · Complaint inspection · Deficient, Provider has date of correction (Jan 31, 2024)

DProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0690 · Complaint inspection · Deficient, Provider has date of correction (Jan 31, 2024)

DEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Complaint inspection · Deficient, Provider has date of correction (Jan 31, 2024)

DSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0842 · Complaint inspection · Deficient, Provider has date of correction (Jan 31, 2024)

FProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Deficient, Provider has date of correction (Jul 20, 2023)

DHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0578 · Deficient, Provider has date of correction (Jul 20, 2023)

DImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0580 · Deficient, Provider has date of correction (Jul 20, 2023)

DProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0623 · Deficient, Provider has date of correction (Jul 20, 2023)

DCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0644 · Deficient, Provider has date of correction (Jul 20, 2023)

DCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0655 · Deficient, Provider has date of correction (Jul 20, 2023)

DDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0656 · Deficient, Provider has date of correction (Jul 20, 2023)

DPlan the resident's discharge to meet the resident's goals and needs.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0660 · Deficient, Provider has date of correction (Jul 20, 2023)

DProvide care and assistance to perform activities of daily living for any resident who is unable.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0677 · Deficient, Provider has date of correction (Jul 20, 2023)

DProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0690 · Deficient, Provider has date of correction (Jul 20, 2023)

DProvide safe and appropriate respiratory care for a resident when needed.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0695 · Deficient, Provider has date of correction (Jul 20, 2023)

DProvide safe, appropriate pain management for a resident who requires such services.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0697 · Deficient, Provider has date of correction (Jul 20, 2023)

DProvide safe, appropriate dialysis care/services for a resident who requires such services.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0698 · Deficient, Provider has date of correction (Jul 20, 2023)

DTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0700 · Deficient, Provider has date of correction (Jul 20, 2023)

DProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Deficient, Provider has date of correction (Jul 20, 2023)

DImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0758 · Deficient, Provider has date of correction (Jul 20, 2023)