Cycle 1
Health 2024-12-12 · Fire 2024-12-12
0 health deficiencies
No concentrated health issue counts in this cycle.
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Greenfield, WI
Clement Manor Health Care Center
5-star overall rating with 5-star inspections with 8 fire-safety deficiencies in the latest cycle
3939 S 92nd St, Greenfield, WI
(414) 321-1800
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
40
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1982-11-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.81
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.95
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.51
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.26
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.76
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.06
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.61
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.87
CMS adjusted RN staffing hours
Adjusted total hours
4.60
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
62%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,121
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.73
Composite VBP score used to determine payment impact.
Payment multiplier
0.9847
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.63
Baseline 20.76% · Performance 20.21% · Measure score 2.63 · Achievement 2.63 · Improvement 0.96
Healthcare-associated infections
1.68
Baseline 6.92% · Performance 7.33% · Measure score 1.68 · Achievement 1.68 · Improvement 0
Total nurse turnover
3.55
Performance 49.18% · Measure score 3.55 · Achievement 3.55 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.23
Baseline 4.78 hours · Performance 4 hours · Measure score 3.23 · Achievement 3.23 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.94% |
10.72%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 100 · Observed rate 16% · Lower 95% interval 9.57% |
| Discharge to community | 53.1% |
50.57%
2.5 pts better
|
No Different than the National Rate · Eligible stays 99 · Observed rate 48.48% · Lower 95% interval 42.06% |
| Medicare spending per beneficiary | 1.26 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 93.62% |
95.27%
1.6 pts worse
|
Numerator 44 · Denominator 47 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 47 |
| Discharge self-care score | 83.78% |
53.69%
30.1 pts better
|
Numerator 31 · Denominator 37 |
| Discharge mobility score | 70.27% |
50.94%
19.3 pts better
|
Numerator 26 · Denominator 37 |
| Pressure ulcers or injuries, new or worsened | 6.38% |
2.29%
4.1 pts worse
|
Numerator 3 · Denominator 47 · Adjusted rate 5.63% |
| Healthcare-associated infections requiring hospitalization | 7.33% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 75 · Observed rate 6.67% · Lower 95% interval 4.39% |
| Staff COVID-19 vaccination coverage | 1.85% |
8.2%
6.3 pts worse
|
Numerator 3 · Denominator 162 |
| Staff flu vaccination coverage | 98.8% |
42%
56.8 pts better
|
Numerator 164 · Denominator 166 |
| Discharge function score | 78.38% |
56.45%
21.9 pts better
|
Numerator 29 · Denominator 37 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 24 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.7%
4.3 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.2%
3.2 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
5.0%
5 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
4.9%
4.9 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.7% |
16.6%
4.1 pts worse
|
19.6%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 19.0% · Q4 22.7% · 4Q avg 20.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
16.7%
16.7 pts better
|
16.7%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.5% |
17.3%
7.8 pts better
|
14.9%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q4 10.0% · 4Q avg 9.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
2.3%
1.8 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.1% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.8% |
3.0%
3.8 pts worse
|
1.7%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 10.0% · Q3 3.8% · Q4 6.9% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 34.5% |
25.5%
9 pts worse
|
19.8%
14.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 48.8% · Q2 16.9% · Q3 34.6% · Q4 36.6% · 4Q avg 34.5% |
| Percentage of long-stay residents with pressure ulcers | 2.8% |
5.5%
2.7 pts better
|
5.1%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.1% · Q3 2.3% · Q4 4.3% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.3% |
86.8%
7.5 pts better
|
81.7%
12.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.8% · Q2 95.4% · Q3 94.4% · Q4 91.7% · 4Q avg 94.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.5% |
15.0%
9.5 pts better
|
12.0%
6.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.5% · Observed 4.2% · Expected 8.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.9% |
82.2%
11.7 pts better
|
79.7%
14.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.4% |
22.7%
3.7 pts worse
|
23.9%
2.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.4% · Observed 18.8% · Expected 16.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-25 · Fire 2023-10-25
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (5 deficiencies)
Cycle 3
Health 2022-07-07 · Fire 2022-07-07
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-12-27
F · Potential for more than minimal harm
2024-12-12
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-01-02
F · Potential for more than minimal harm
2024-12-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-30
E · Potential for more than minimal harm
2024-12-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-27
E · Potential for more than minimal harm
2024-12-12
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-01-07
E · Potential for more than minimal harm
2024-12-12
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-12-12
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-12-24
D · Potential for more than minimal harm
2024-12-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-01-03
F · Potential for more than minimal harm
2023-10-25
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-11-14
F · Potential for more than minimal harm
2023-10-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-09
E · Potential for more than minimal harm
2023-10-25
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-11-22
E · Potential for more than minimal harm
2023-10-25
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-11-22
D · Potential for more than minimal harm
2023-10-25
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-11-09
D · Potential for more than minimal harm
2023-10-25
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-11-13
D · Potential for more than minimal harm
2023-10-25
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-11-13
F · Potential for more than minimal harm
2022-07-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-08-08
F · Potential for more than minimal harm
2022-07-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-07-23
E · Potential for more than minimal harm
2022-07-07
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-08-07
E · Potential for more than minimal harm
2022-07-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-08-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2023-10-25
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-11-22
D · Potential for more than minimal harm
2023-10-25
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-11-22
D · Potential for more than minimal harm
2023-10-25
F758 · Pharmacy Service Deficiencies
Health
Implement 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.
Corrected 2023-11-22
D · Potential for more than minimal harm
2023-10-25
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2023-11-22
Penalties and ownership
What sits behind the stars
Ownership
Chang, Steve
Contracted Managing Employee · Individual
Dougherty, Philip
Corporate Director · Individual
Ferger, Dennis
Corporate Officer · Individual
Ferger, Dennis
W-2 Managing Employee · Individual
Franciscan Sisters Of Christian Charity Sponsored Ministries, Inc.
Operational/Managerial Control · Organization
Heindel, John
Corporate Officer · Individual
Loch, Timothy
Contracted Managing Employee · Individual
Loewus, Carly
W-2 Managing Employee · Individual
Maher, Ann
Corporate Officer · Individual
Schulte, Judeen
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Maplewood Center
West Allis, WI
1-star overall rating with 1-star inspections with $508,068 in total fines with 26 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
#2
Complete Care at Hales Corners
Hales Corners, WI
4-star overall rating with 4-star inspections with $17,934 in total fines with 9 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Greendale Park Nursing and Rehab
Greendale, WI
1-star overall rating with 1-star inspections with $271,160 in total fines with 19 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
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