Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Clement Manor Health Care Center during CMS and state inspections, most recent first.
Incomplete Investigation of Alleged Misappropriation: A cognitively intact resident reported fraudulent charges on a bank account, and the resident’s family suspected possible staff involvement. The facility interviewed staff and contacted police, but the investigation did not include resident interviews to determine whether other residents had missing credit cards or money, and no documentation showed staff education related to misappropriation after the allegation.
Two severely cognitively impaired residents engaged in separate resident-to-resident physical abuse incidents in a dining area. In one event, a resident verbally threatened harm toward another, then kicked the other resident’s wheelchair and pulled her hair until staff intervened. In a later event, the other resident intentionally pinched the first resident’s hand and attempted to run over her feet with a wheelchair, causing the resident to cry. Staff, social services, and the Administrator acknowledged these intentional acts as abuse, contrary to the facility’s abuse-prevention policy.
A resident with a history of DVT was receiving Eliquis 5 mg BID when the Medical Director ordered Paxlovid, prompting a pharmacist-identified drug interaction and a new order to reduce Eliquis to 2.5 mg BID for several days. Due to communication failures between the prescriber, pharmacy, and nursing staff, and confusion over the new Eliquis dose, nursing staff inconsistently held and administered the 5 mg dose while also giving the 2.5 mg dose. As a result, the resident received overlapping Eliquis doses totaling 7.5 mg on multiple days during Paxlovid therapy, contrary to the physician’s dose reduction order and the facility’s policy for accurate dispensing and interaction screening.
Incomplete Investigation of Alleged Misappropriation
Penalty
Summary
The facility did not ensure that an allegation of misappropriation involving a cognitively intact resident was thoroughly investigated. R33, who had diagnoses including Parkinson’s disease and Type 2 diabetes, reported being overwhelmed after learning that fraudulent charges had been made on the resident’s bank account. The resident’s admission MDS documented cognitive intactness. The allegation involved suspected unauthorized transactions on R33’s credit card, with the resident’s family expressing concern that a staff member may have been involved. The facility’s incident documentation stated that the bank notified the COO of suspected misappropriation and that law enforcement was contacted. Facility staff interviewed staff members who worked during the relevant shifts and reviewed names provided by the bank through HR and Scheduling, but the investigation did not include resident interviews. Surveyor review found no interviews with other residents to determine whether any other resident had a missing credit card or missing money. The facility also did not document staff education to prevent misappropriation after the allegation. During interviews, the SW, DOSW, and CA each confirmed that the investigation was handled by Social Work and administration, and that police were involved. The SW stated resident interviews were typically completed but could not confirm them for this case. The DOSW stated she was not asked to complete resident interviews, and the CA acknowledged the concern when informed that other residents had not been interviewed. The surveyor determined the investigation was not thorough because it did not include resident interviews to identify the potential scope of the concern.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two severely cognitively impaired residents from physical abuse by each other on two separate occasions. One resident, admitted in 2021 with a BIMS score of 3/15 and dependent on staff for ADLs, approached another resident in the dining room and asked an LPN to take the other resident outside and kill her. After being verbally redirected and moved away, the resident wheeled herself back, kicked the other resident’s wheelchair, and later pulled the other resident’s hair and would not let go until staff intervened. Staff documented that the resident had no behaviors directed to self or others on the most recent MDS assessment prior to this event. The other resident, admitted in 2022 with a BIMS score of 1/15 and also documented as having no behaviors on the most recent MDS, later initiated a separate altercation in the dining room. During this incident, the resident approached the first resident, intentionally pinched the back of her hand, and attempted to run over her feet with a wheelchair. Staff witnesses, including CNAs, described these actions as intentional and confirmed that the involved resident was crying as a result. Social services staff and the Administrator acknowledged that both resident-to-resident altercations constituted abuse under the facility’s policy, which states that residents will not be subjected to abuse by anyone, including other residents.
Medication Management and Communication Failures with Eliquis Dose Reduction During Paxlovid Therapy
Penalty
Summary
The deficiency involves the facility’s failure to properly manage and communicate physician-ordered changes to an anticoagulant (Eliquis) when an antiviral (Paxlovid) was initiated for a resident with a history of deep vein thrombosis (DVT). The resident was admitted on 04/07/22 and had an existing order for Eliquis 5 mg every 12 hours, with the last dose to be administered on 02/11/26. On 02/02/26, the Medical Director ordered Paxlovid 150 mg-100 mg twice daily for four days. The pharmacy’s receipt of the Paxlovid order generated a level one interaction flag because the resident was also on Eliquis, and the pharmacist contacted the Medical Director, who then ordered a reduction of Eliquis to 2.5 mg twice daily for eight days. Despite this new order, the facility’s medication administration records and staff interviews show that the Eliquis dose reduction and hold parameters were not consistently implemented or communicated. The Medication Record for 02/2026 shows that Eliquis 5 mg doses were variably held and administered: the AM dose was held on multiple days between 02/04/26 and 02/08/26, and the PM dose was held on several days but still administered on 02/06/26 and 02/07/26. A separate Physician Orders document dated 02/03/26 reflects the Eliquis 2.5 mg twice daily order, with administration documented from 02/03/26 to 02/08/26. As a result, the resident received both Eliquis 5 mg and 2.5 mg during overlapping periods, leading to total daily doses of 7.5 mg on some days instead of the intended reduced regimen. Staff interviews further describe communication and process failures contributing to the error. One LPN stated she was unaware of the Eliquis dose reduction, returned the 2.5 mg tablets to the pharmacy upon receipt, and did not place a hold on the 5 mg evening dose, even after later writing the 2.5 mg order for eight days. The nurse supervisor reported that the Medical Director reduced the Eliquis dose due to the resident being placed on Paxlovid and that there was a communication failure regarding this change. The Lead Consultant Pharmacist stated that after the interaction alert and dose reduction, her expectation was that the pharmacist would contact the facility to alert nursing staff of the new order. The DON reported that a new LPN administered Eliquis 7.5 mg on two days, and the facility’s Medication Incident Report documented that three PM doses of Eliquis 5 mg were given when they should have been held, resulting in the resident receiving Eliquis 7.5 mg for three days while on Paxlovid, with the potential for increased risk of severe bleeding noted in the deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Greenfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maplewood Center | 1.2 mi | ★★★★★ | 3 | 0 |
| Complete Care At Hales Corners | 1.8 mi | ★★★★★ | 5 | 0 |
| Greendale Park Nursing And Rehab | 2.9 mi | ★★★★★ | 42 | 0 |
| Resolve At West Allis Respiratory And Rehab | 3 mi | ★★★★★ | 24 | 0 |
| Complete Care At Southpointe | 3.1 mi | ★★★★★ | 19 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.