Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Menominee Health Services during CMS and state inspections, most recent first.
Failure to Document Weekly Wound Assessments: A resident with paraplegia and risk for pressure injuries had a right lower extremity wound first noted as a scabbed area and later described as a black, non-blanchable area, but the chart lacked documented wound assessments, measurements, or descriptions for months despite repeated progress notes referencing the wound. When formal tracking began, the wound was already a stage 3 pressure injury with slough, necrotic tissue, tunneling, undermining, and a nearby eschar-covered wound; the DON and RN confirmed there had been no documented assessments until the tracker was started, despite the facility policy for weekly wound assessment.
A resident with a history of cerebral infarction was at risk for pressure injuries, yet the facility failed to accurately identify and document these injuries. Observations showed the resident's heels on the mattress without pressure-reduction boots, which were not included in the care plan. Despite wound clinic reports indicating stage 3 pressure injuries, the facility's assessments documented them as diabetic ulcers, leading to inadequate care planning.
The facility failed to monitor and maintain nutritional status for two residents. One resident, with a fluid restriction due to renal dialysis, received more fluids than allowed due to lack of coordination between dietary and nursing departments. Another resident experienced significant weight loss without re-weighing or intervention, despite facility policies. These deficiencies highlight failures in implementing fluid restriction and weight monitoring protocols.
The facility failed to update infection control policies and implement appropriate practices for two residents. A resident with influenza A was not placed under proper precautions, lacking signage and antiviral treatment. Another resident's medication administration via G-Tube was mishandled by an RN who did not change gloves or perform hand hygiene. Infection control policies were outdated, contributing to these deficiencies.
The facility failed to properly label and securely store two controlled medications. An opened bottle of morphine sulfate was found without an 'open date' label, and a missing Tramadol HCL tablet was improperly disposed of after being found on the floor. Additionally, a blister pack was improperly taped and stored.
The facility failed to employ a full-time dietitian, certified dietary manager, or certified food service manager to manage the food service department. The Kitchen Manager lacked necessary certifications and training, and the Registered Dietitian focused solely on clinical needs, being on-site for only 13 hours over three months.
The facility failed to employ sufficient staff with the appropriate competencies and skills to carry out the functions of the food and nutrition services. The Kitchen Manager had not completed the Certified Dietary Manager's coursework and had no other relevant food service training. The KM was unfamiliar with sanitizing solutions, chemicals, and cooling logs, and was observed handling clean dishes without washing hands after handling soiled dishes. The kitchen had only six staff members to perform all dietary services.
The facility failed to adhere to food safety and hygiene standards, including improper storage and documentation of food, inadequate sanitizing solutions, poor hand hygiene practices, and faulty equipment. These lapses indicate significant non-compliance with the FDA Food Code 2017.
The facility failed to perform adequate infection surveillance and control, contributing to a Covid-19 outbreak infecting 15 residents. Staff did not adhere to PPE protocols, and the DON admitted to not completing infection control tracking in a timely manner.
The facility failed to provide sufficient time for the Infection Preventionist (IP) to implement the Infection Control program for all 34 residents. The Director of Nursing (DON), who also served as the IP, was observed working as a floor nurse due to staffing issues, limiting her ability to perform infection surveillance activities. The facility lacked ongoing analysis of surveillance data and documentation of follow-up activities in response to infections.
The facility failed to provide written notification to residents or their representatives for transfers to the hospital. Three residents were transferred without written notification, and interviews revealed that the facility relied on phone calls to the POA instead of using the existing form for written notifications.
Failure to Document Weekly Wound Assessments
Penalty
Summary
The facility failed to monitor and document wound assessments and measurements for a resident admitted with paraplegia who was at risk for pressure injuries. On 12/25/25, nursing documentation noted a 1 cm by 2 cm scabbed area on the resident’s right outer ankle, and new orders were entered for Betadine twice daily. A later note on 12/30/25 described the area on the right lateral lower leg above the malleolus as 1.0 cm by 0.5 cm with intact dry, hard black skin and non-blanchable red peri-wound tissue. Although multiple progress notes from 12/30/25 through 4/7/26 referenced a wound on the right lower lateral extremity, there were no documented wound measurements, descriptions, or assessments during that period until a pressure injury tracker was started on 4/7/26. When the pressure injury tracker was implemented, the wound on the right lower lateral extremity was assessed as a stage 3 pressure injury measuring 6.4 cm by 2.5 cm by 0.5 cm with slough and necrotic tissue, and the record noted two 10-day antibiotic courses in March 2026 for wound infection. A follow-up assessment on 4/14/26 documented the wound at 6.4 cm by 2.6 cm by 0.5 cm with increased slough and necrotic tissue, and a new wound was identified nearby. On 4/22/26, nursing staff observed the wound with necrotic tissue, tunneling, and undermining, and an eschar-covered wound superior to the area was also measured. The DON and RN confirmed there were no documented wound assessments until 4/7/26, and the DON stated the expectation was for weekly wound documentation; the facility’s policy required current wounds to be assessed at least every seven days.
Failure to Identify and Document Pressure Injuries
Penalty
Summary
The facility failed to accurately identify and document pressure injuries for a resident who was at risk for developing such injuries. The resident, who had a primary diagnosis of cerebral infarction and was coded as having diabetic foot ulcers, was observed with both heels directly on the mattress without the use of pressure-reduction boots, which were found in a chair in the room. Despite a physician's order for dressings on the resident's right heel and lateral plantar area, there was no order for pressure-reduction boots, and the care plan did not include instructions for their use. The facility's wound assessments consistently documented the wounds as diabetic ulcers, despite wound clinic reports and the attending physician's notes indicating they were stage 3 pressure injuries. The facility's Regional Nurse and wound nurse, RN C, both failed to recognize and document the wounds as pressure injuries. RN C admitted to not reviewing the wound clinic reports, which clearly identified the wounds as stage 3 pressure injuries, and continued to document them as diabetic wounds based on the attending physician's initial assessment. This misidentification and lack of proper documentation led to the absence of an appropriate care plan for pressure injuries, leaving the resident without necessary interventions to prevent further skin breakdown.
Deficiencies in Nutritional Monitoring and Fluid Restriction
Penalty
Summary
The facility failed to provide adequate care and services to monitor and maintain acceptable nutritional status for two residents, R11 and R22. For R11, who was admitted with diagnoses including stroke, dementia, diabetes, and dependence on renal dialysis, the facility did not have an individualized plan for the 1500 cc fluid restriction. The dietary department served more fluids than the facility's Fluid Restriction Template allowed, and there was no coordination between the dietary and nursing departments to ensure compliance with the fluid restriction. The Registered Dietitian (RD) did not divide the fluid restriction between departments, and the facility's policy was not followed, leading to instances where the fluid restriction was exceeded. For R22, the facility failed to address significant weight loss. R22's recorded weights showed a gradual decrease from 216 pounds to 195.5 pounds over several months. Despite the care plan's focus on maintaining weight and the facility's policy requiring re-weighing for a five-pound weight change, no re-weight was conducted for the significant weight loss observed. The RD confirmed that weight loss was discussed in At Risk resident meetings, but no recommendations or interventions were made to address the weight loss, and no follow-up weight was obtained. The facility's policies on fluid restriction and weight monitoring were not effectively implemented, leading to deficiencies in the care provided to R11 and R22. The lack of coordination and documentation, as well as the failure to adhere to established protocols, contributed to the potential for fluid imbalance in R11 and unaddressed weight loss in R22.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to update its infection control policies annually and implement appropriate infection prevention and control practices for two residents. Resident #28 was admitted to the facility and later tested positive for influenza type A. Despite this, there was no signage indicating Transmission-Based Precautions (TBP) for a transmissible respiratory illness on the door of R28's room, which was shared with a roommate. The facility did not post precautionary information at the entrance door to inform visitors of the contagious illness, and there was no physician's order for droplet precautions or antiviral medication for R28. The Infection Preventionist confirmed that these measures should have been in place and acknowledged that unoccupied rooms were available but not utilized for R28. Resident #4 was observed during a medication administration process where Registered Nurse (RN) A failed to follow proper infection control protocols. RN A donned Personal Protective Equipment (PPE) but did not change gloves or perform hand hygiene while setting up and administering medications via R4's G-Tube. RN A used the same gloves to handle various items, including a laptop, medication cart, and narcotic book, and did not sanitize the stethoscope used on R4. RN A admitted to not following proper donning and doffing procedures and infection control techniques, acknowledging the oversight during the medication pass. The facility's infection prevention and control policies were not updated or reviewed annually, with the last revisions dating back to 2023 and 2024. The policies outlined the need for droplet precautions and signage for residents with suspected or confirmed influenza, as well as the use of PPE and hand hygiene for contact precautions. The facility's failure to adhere to these policies and guidelines contributed to the deficiencies observed in the care of R28 and R4.
Improper Labeling and Storage of Controlled Medications
Penalty
Summary
The facility failed to ensure that two controlled medications were properly labeled and securely stored. During an observation of a medication cart manned by an LPN, an opened bottle of morphine sulfate prescribed to a resident was found without an 'open date' label. The LPN confirmed that the facility's policy required opened bottles and vials of medication to be dated when first opened. A review of the resident's controlled substance record showed that the morphine sulfate had been received by the facility and administered twice, but the bottle remained unlabeled with the date it was opened. In another instance, during a medication pass to a resident, an LPN prepared seven medications in a plastic medication cup but found that a white tablet from a blister pack of Tramadol HCL did not fall into the cup. The LPN and the surveyor searched for the missing pill, which was eventually found on the floor and disposed of incorrectly in a sharp's container. Additionally, the blister pack was found to have paper tape covering a previously opened pill slot, which the LPN confirmed was not acceptable practice. The Director of Nursing also confirmed that taping a previously opened narcotic closed and storing it for future use was against facility policy.
Failure to Employ Qualified Dietary Staff
Penalty
Summary
The facility failed to employ a full-time dietitian, certified dietary manager, or certified food service manager to manage the food service department. During an interview, the Kitchen Manager (KM) stated she had not completed the Certified Dietary Manager's (CDM) coursework, nor had she begun or signed up for the course. Additionally, the KM had no other food service training such as a Certified Food Manager or Serve Safe certification. The Registered Dietitian (RD) did not provide consultation on food service sanitation or other kitchen issues, focusing instead on clinical needs. The Nursing Home Administrator (NHA) confirmed that the RD provided clinical support and documented that the RD was on-site for a total of 13 hours over three months (January, February, and March 2024).
Insufficient Staffing and Training in Food and Nutrition Services
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skills to carry out the functions of the food and nutrition services. The Kitchen Manager (KM) had not completed the Certified Dietary Manager's (CDM) coursework and had no other relevant food service training. The KM was unfamiliar with the testing of sanitizing solutions, the chemicals used as sanitizing agents, and the use of cooling logs for tracking leftover foods. Additionally, the KM was observed handling clean dishes without washing her hands after handling soiled dishes, citing a lack of staff as the reason. The kitchen had only six staff members to perform all dietary services, including food preparation, service, dishwashing, cleaning, ordering, and storage.
Food Safety and Hygiene Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an initial observation, a 2-gallon container of spaghetti sauce was found in the refrigerator without documented cooling processes. The kitchen manager admitted that the cook responsible had not documented the cooling process and that she was working on a form for staff to follow. Additionally, the same container was observed the next day, and it was only discarded after the surveyor's intervention. Furthermore, two buckets with wiping cloths were found on a food preparation table, one containing a detergent and water mixture and the other clear water. The kitchen manager was unaware of the proper concentration of the sanitizing solution and could not locate any test strips to verify its effectiveness. The solution tested at zero parts per million, indicating the absence of sanitizer. The kitchen manager also admitted to using a hydrogen peroxide solution from a housekeeping closet without knowing its proper concentration for food service use. The facility also demonstrated poor hand hygiene practices. The kitchen manager was observed handling soiled dishes and then clean dishes without washing her hands. Another cook was seen picking up a plastic container from the floor and returning to meal preparation without washing her hands. Additionally, the mechanical dish machine was found to be improperly sanitizing food contact surfaces, with the maximum registering thermometer showing a temperature of 145.7°F, below the required 160°F. The kitchen manager was unaware of the appropriate corrective actions and could not produce any previous logs demonstrating proper sanitizing of the machine. The surveyor had to provide adhesive Thermolabels to demonstrate proper sanitizing procedures. Other deficiencies included a direct connection of the Folgers coffee machine to the potable water supply without an approved backflow preventer. The maintenance supervisor incorrectly identified a device on the water supply line as an approved backflow prevention device. Additionally, two hand sinks in the main kitchen and one near the dishwashing room were constantly running and could not be shut off, a condition that had been ongoing for over two years. These findings indicate a lack of adherence to the FDA Food Code 2017 and demonstrate significant lapses in food safety and hygiene practices within the facility.
Inadequate Infection Control and Surveillance
Penalty
Summary
The facility failed to perform process and outcome surveillance for all 34 residents, which possibly contributed to a Covid-19 outbreak infecting 15 residents. The Director of Nursing (DON), who also served as the Infection Preventionist (IP), admitted to not having completed the March infection control tracking. The facility lacked real-time tracking and a system of surveillance to identify possible communicable diseases or infections before they could spread. This deficiency was observed during an interview with the DON/IP, who stated that infection control data was only compiled in preparation for the monthly Quality Assurance Performance Improvement (QAPI) meeting, rather than on an ongoing basis. Multiple instances of staff failing to adhere to infection control protocols were observed. For example, a staff member entered a Covid-19 positive resident's room without wearing the required personal protective equipment (PPE) and admitted to not realizing the resident was positive. Another staff member was seen removing a dirty N95 mask with bare hands and contaminating clean masks without performing hand hygiene. Additionally, a maintenance director exited a Covid-19 positive room and placed a face shield back on his head without disinfecting it. These actions were in direct violation of the facility's infection prevention and control policies. Further observations revealed that staff did not follow proper PPE protocols when exiting Covid-19 positive rooms. One CNA removed PPE but did not perform hand hygiene before handling clean supplies and a meal tray. Another RN administered medication and tube feeding without wearing gloves and used bare hands to remove an isolation gown and face shield. These actions were contrary to the facility's Enhanced Barrier Precautions policy and the Contact/Droplet Precautions signage, which outlined specific steps for donning and doffing PPE and performing hand hygiene to prevent the spread of infections.
Inadequate Time for Infection Preventionist to Implement Infection Control Program
Penalty
Summary
The facility failed to provide sufficient time for the Infection Preventionist (IP) to implement the Infection Control program for all 34 residents. The Director of Nursing (DON), who also served as the IP, was observed to be working as a floor nurse due to staffing issues, which limited her ability to perform infection surveillance activities. During a Covid-19 outbreak involving 15 residents, the DON/IP was unable to discuss infection control practices promptly due to her floor nursing duties. The facility lacked ongoing analysis of surveillance data and documentation of follow-up activities in response to infections, and there was no real-time tracking system to identify possible communicable diseases or infections before they could spread to other persons in the facility. The DON/IP admitted that she had been working the floor due to staffing issues, making it difficult to fulfill her responsibilities as both DON and IP. The staffing schedule revealed that the DON/IP had been scheduled as a floor nurse for 12 of the last 23 days in March and 12 of the first 21 days in April, including five 12-hour shifts. This dual role hindered her ability to properly assess, develop, implement, monitor, and manage the infection control program. The facility's policy on Infection Prevention and Control Program outlined the responsibilities of the IP, which included oversight of the program, surveillance activities, and documentation of incidents, but these duties were not being adequately performed due to the DON/IP's additional floor nursing responsibilities.
Failure to Provide Written Notification for Resident Transfers
Penalty
Summary
The facility failed to notify the resident or their representative in writing with the reason for a transfer out of the facility for three residents. Resident #3 was transferred to the hospital on 3/30/24 without written notification to their representative. Resident #13 was transferred to the hospital on 1/3/24, and the nursing progress note indicated the transfer but lacked written notification to the representative. Resident #17 was transferred to the hospital on 9/13/23 without written notification to their representative. Interviews with the Social Services Director, Director of Nursing (DON), and Nursing Home Administrator revealed that the facility did not have a process in place for sending written notifications, relying instead on phone calls to the Power of Attorney (POA). The DON acknowledged the existence of a form for written notification but admitted it was not being used.
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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 Menominee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Luther Home | 3.2 mi | ★★★★★ | 16 | 0 |
| Rennes Health And Rehab Center-east | 7.1 mi | ★★★★★ | 3 | 0 |
| Rennes Health And Rehab Center-west | 8.3 mi | ★★★★★ | 3 | 0 |
| Roubal Care And Rehabilitation Center | 20.1 mi | ★★★★★ | 0 | 0 |
| Newcare | 20.6 mi | ★★★★★ | 14 | 0 |
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