2 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
10 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Greenfield, WI
4-star overall rating with 3-star inspections with $89,823 in total fines with 2 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
4500 W. Loomis Rd., Greenfield, WI
(414) 325-5300
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
174
Certified beds
Average residents
101
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Complete Care
Operator or chain grouping
Approved since
1996-09-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
85 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
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
RN hours / resident day
0.80
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.69
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.04
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.53
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.49
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.16
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.59
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.69
CMS adjusted RN staffing hours
Adjusted total hours
3.03
CMS adjusted total nurse staffing hours
Case-mix index
1.59
Higher values indicate more complex resident acuity
RN turnover
13%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Program rank
5,237
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.90
Composite VBP score used to determine payment impact.
Payment multiplier
0.9902
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
3.05
Baseline 20.79% · Performance 20.02% · Measure score 3.05 · Achievement 3.05 · Improvement 1.56
Healthcare-associated infections
8.04
Baseline 8.43% · Performance 5.50% · Measure score 8.04 · Achievement 7.82 · Improvement 8.04
Total nurse turnover
2.36
Performance 54.03% · Measure score 2.36 · Achievement 2.36 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.31
Baseline 3.51 hours · Performance 3.45 hours · Measure score 1.31 · Achievement 1.31 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.68% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 130 · Observed rate 13.85% · Lower 95% interval 8.75% |
| Discharge to community | 55.83% |
50.57%
5.3 pts better
|
No Different than the National Rate · Eligible stays 105 · Observed rate 50.48% · Lower 95% interval 46.64% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.75% |
95.27%
3.5 pts better
|
Numerator 79 · Denominator 80 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 80 |
| Discharge self-care score | 53.66% |
53.69%
About the same
|
Numerator 22 · Denominator 41 |
| Discharge mobility score | 41.46% |
50.94%
9.5 pts worse
|
Numerator 17 · Denominator 41 |
| Pressure ulcers or injuries, new or worsened | 2.5% |
2.29%
0.2 pts worse
|
Numerator 2 · Denominator 80 · Adjusted rate 2.28% |
| Healthcare-associated infections requiring hospitalization | 5.5% |
7.12%
1.6 pts better
|
No Different than the National Rate · Eligible stays 67 · Observed rate 1.49% · Lower 95% interval 2.64% |
| Staff COVID-19 vaccination coverage | 2.61% |
8.2%
5.6 pts worse
|
Numerator 3 · Denominator 115 |
| Staff flu vaccination coverage | 51.26% |
42%
9.3 pts better
|
Numerator 61 · Denominator 119 |
| Discharge function score | 51.22% |
56.45%
5.2 pts worse
|
Numerator 21 · Denominator 41 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 42 · Denominator 42 |
| Resident COVID-19 vaccinations up to date | 42.59% |
25.2%
17.4 pts better
|
Numerator 23 · Denominator 54 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.6% |
95.7%
1.9 pts better
|
93.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.3% · Q2 100.0% · Q3 95.9% · Q4 97.4% · 4Q avg 97.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.1% |
95.0%
3.9 pts worse
|
95.5%
4.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.1% |
| 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 | 15.0% |
5.0%
10 pts worse
|
11.4%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 4.6% · Q3 14.3% · Q4 33.8% · 4Q avg 15.0% |
| Percentage of long-stay residents who lose too much weight | 3.5% |
4.9%
1.4 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 1.9% · Q3 5.4% · Q4 3.4% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.2% |
16.6%
2.4 pts better
|
19.6%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.5% · Q2 14.8% · Q3 14.3% · Q4 12.1% · 4Q avg 14.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.8% |
16.7%
10.9 pts better
|
16.7%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 5.0% · Q3 6.8% · Q4 6.8% · 4Q avg 5.8% · 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 ability to walk independently worsened | 34.9% |
21.1%
13.8 pts worse
|
16.3%
18.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 34.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.7% |
17.3%
6.6 pts better
|
14.9%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 16.0% · Q3 3.8% · Q4 1.8% · 4Q avg 10.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.3%
2.3 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.8% |
3.0%
2.8 pts worse
|
1.7%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 7.2% · Q3 4.1% · Q4 6.4% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.9% |
25.5%
4.4 pts worse
|
19.8%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 31.1% · Q3 33.8% · Q4 28.5% · 4Q avg 29.9% |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
5.5%
3.4 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 1.5% · Q3 1.8% · Q4 2.2% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 72.6% |
86.8%
14.2 pts worse
|
81.7%
9.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 76.9% · Q2 73.7% · Q3 71.6% · Q4 69.2% · 4Q avg 72.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.0% |
15.0%
6 pts better
|
12.0%
3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.0% · Observed 8.9% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.3%
0.7 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.8% · Q3 0.8% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 79.5% |
82.2%
2.7 pts worse
|
79.7%
0.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 79.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.7% |
22.7%
2 pts better
|
23.9%
3.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.7% · Observed 21.5% · Expected 24.8% · Used in QM five-star |
Survey summary
Top issue: Resident Assessment and Care Planning (2 deficiencies)
10 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Top issue: Quality of Life and Care (10 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-10-17
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-11-13
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-12
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-01-31
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-01-31
Fire Safety
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Corrected 2024-11-11
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-12
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-10-17
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-10-17
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-10-17
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-09-11
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-09-11
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-09-11
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2024-02-13
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-09-11
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-09-11
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-05-01
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-05-01
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 2022-05-01
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-05-01
Inspection history
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-11-06
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-10-18
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-09-13
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-13
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-09-13
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-13
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-13
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-09-13
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-09-13
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-09-13
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2022-06-30
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-06-30
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-07-30
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-06-30
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-06-30
Health
Provide and implement an infection prevention and control program.
Corrected 2022-06-30
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-06-30
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2022-06-30
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-06-30
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-06-30
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-06-30
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-06-30
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-06-30
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2022-06-30
Health
Honor 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.
Corrected 2022-06-30
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-07-30
Health
Respond appropriately to all alleged violations.
Corrected 2022-06-30
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-07-30
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-06-30
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-06-30
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-06-30
Health
Try 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.
Corrected 2022-06-30
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2022-06-30
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2022-06-30
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 2022-06-30
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-06-30
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-06-30
Health
Implement a program that monitors antibiotic use.
Corrected 2022-06-30
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2022-06-30
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-06-30
Penalties and ownership
Fine · fine $89,823
Fine
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Organization
Corporate Officer · Individual
Operational/Managerial Control · Individual
Nearby options
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Milwaukee, WI
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