Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Neighbors - Central Neighborhood (the) during CMS and state inspections, most recent first.
The facility did not maintain accurate or complete infection surveillance records, with missing data on infection onset, isolation practices, lab tests, and antibiotic use. During an Influenza A outbreak, there was no clear documentation of outbreak management or follow-up actions. The DON and ADON acknowledged gaps in recordkeeping and surveillance, including failure to document staff infections and to include a resident with a UTI on the infection line list.
The facility did not ensure that the designated IP, the DON, had completed required infection control training, including the CDC post-assessment, and the ADON assisting with infection control duties was still in training. No other certified staff were overseeing infection control for the unit.
Four residents were not offered or educated about the pneumococcal vaccine despite being due, and there was no documentation of vaccine declination or education in their records. The facility did not follow its own policy or CDC guidelines for identifying and documenting pneumococcal immunization status.
A resident with multiple comorbidities and limited mobility developed a stage 2 pressure injury after staff failed to consistently implement and document required wound care interventions, including timely application of prescribed dressings and pressure-relieving equipment. Staff did not update care plans or follow physician orders, leading to inadequate prevention and treatment of the pressure injury.
A facility did not properly implement its Infection Prevention and Control Program, resulting in a resident with a UTI being omitted from infection surveillance records and lacking documentation on whether McGeer's criteria for antibiotic use were met. The resident's condition worsened, requiring hospitalization and a change in antibiotics. Staff interviews revealed gaps in documentation and tracking of antibiotic use, contrary to facility policy.
Deficient Infection Surveillance and Documentation During Outbreak
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by incomplete and inaccurate infection surveillance processes from January 2025 through May 2025. The infection surveillance line lists reviewed by the surveyor were missing critical data each month, including well dates, details on resident and staff isolation, onset of symptoms, types of laboratory tests completed, and the rationale for antibiotic use. Additionally, there was a lack of documentation regarding the location of infections, staff-resident contact tracing, and summary or analysis of infection outbreaks, specifically during an Influenza A outbreak in February 2025. During interviews, the Director of Nursing (DON) acknowledged that infection logs and outbreak data were combined into a single spreadsheet, but could not provide comprehensive documentation or summaries related to outbreaks or infection control activities. The DON also admitted to not maintaining records of staff infections and surveillance after the previous DON left the position. The Assistant Director of Nursing (ADON) reported using McGeer's criteria for infection identification but did not document whether criteria were met, and there was an instance where a resident diagnosed with a UTI and prescribed antibiotics was not included in the infection line list for that month. The facility's infection surveillance logs lacked documentation of follow-up actions in response to surveillance findings, such as outbreaks, and did not include observations of staff practices or identification of ineffective infection control measures. The absence of thorough and accurate infection surveillance, incomplete documentation, and lack of analysis or summary of infection control activities contributed to the deficiency, with the potential to affect all residents in the facility.
Infection Preventionist Lacked Required Training
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) was properly trained in infection prevention and control, as required. During an interview, the Director of Nursing (DON), who was assigned as the IP, was unable to provide evidence of completed infection control certification and was unaware that a post-assessment from the CDC training was required. The surveyor observed on the DON's computer that the post-assessment for infection control training had not been completed. The DON confirmed this lack of completion and stated an intention to complete the assessment. Additionally, the Assistant Director of Nursing (ADON), who was assisting with infection control duties, was still in training and not yet certified. No other staff were reported to be overseeing infection control duties for the affected unit.
Failure to Ensure Pneumococcal Vaccination Offer and Documentation
Penalty
Summary
The facility failed to maintain a comprehensive system to ensure that residents received pneumococcal immunizations as recommended. For four out of five sampled residents, immunization records indicated that pneumococcal vaccinations were due or the last administration date was either unknown or exceeded the recommended interval. There was no documentation in the medical records that these residents had been offered the pneumococcal vaccine, received education about it, or had signed declination forms if they refused the vaccine. The facility's policy required identification of residents needing the vaccine and the use of a decision tree to determine eligibility, but this process was not followed for the affected residents. During interviews and record reviews, it was confirmed that the residents in question had not been offered the pneumococcal vaccine upon admission or during their stay, despite being due for it according to CDC guidelines and facility policy. The Director of Nursing acknowledged the lapse in the process and indicated awareness that the residents were overdue for vaccination, but no evidence was found in the records to show that the required steps had been taken to offer, educate, or document refusal of the vaccine for these residents.
Failure to Provide Timely Pressure Ulcer Prevention and Treatment
Penalty
Summary
A resident with multiple complex medical diagnoses, including acute respiratory failure, chronic kidney disease, diabetes, morbid obesity, and limited mobility, was admitted to the facility and identified as being at moderate risk for pressure injury (PI) development. Initial skin and Braden assessments documented the resident's risk, but the Minimum Data Set (MDS) assessment for PI risk had not yet been completed. Despite the resident's risk status, the facility failed to implement and update necessary interventions after shearing was first observed on the resident's coccyx. On several occasions, staff did not follow physician orders for wound care and pressure injury prevention. For example, a prescribed foam dressing was not consistently applied as ordered, and a nurse removed the dressing to allow the wound to air dry without consulting the provider or updating treatment orders. Additionally, the facility did not promptly apply an air mattress or alternative interventions when equipment was delivered, and there was a lack of timely and accurate documentation regarding the resident's skin condition and Braden scores. The care plan and Master Communication Sheet (MAS) were not updated to reflect new interventions after the initial identification of skin breakdown. Interviews with staff revealed confusion and lack of clarity regarding the resident's wound care plan and the implementation of preventive measures. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged that interventions such as repositioning and wound care should have been initiated and documented following the first signs of shearing. The failure to update care plans, follow treatment orders, and implement timely interventions contributed to the development and progression of a stage 2 pressure injury in the resident.
Failure to Monitor and Document Antibiotic Use in Infection Control Program
Penalty
Summary
The facility failed to establish and implement an effective Infection Prevention and Control Program (IPCP) that included an Antibiotic Stewardship Program with protocols and a system to monitor antibiotic use. The facility's policy on antibiotic stewardship, last reviewed in 2012, required the Infection Preventionist (IP) to conduct infection surveillance, track multidrug-resistant organisms (MDROs), and collect data on antibiotic use, including whether appropriate tests such as cultures were obtained before starting antibiotics. However, a review of the infection surveillance line lists from January to May 2025 revealed that a resident who developed a urinary tract infection (UTI) in March 2025 and was started on antibiotics was not included in the March infection line list. The resident's condition worsened, leading to hospitalization and a change in antibiotic therapy. During interviews, the Assistant Director of Nursing (ADON) stated that McGeer's criteria were used to determine the need for antibiotics but admitted that documentation of whether the criteria were met was not maintained. The Director of Nursing (DON) acknowledged that the resident with the UTI had been missed on the infection line list and was unsure how this occurred, further noting that the infection line lists needed to be revamped. These findings demonstrate that the facility did not ensure proper infection surveillance, documentation, and monitoring of antibiotic use as required by their own policy and regulatory standards.
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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 Menomonie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Neighbors - East Neighborhood (the) | 0.1 mi | ★★★★★ | 5 | 0 |
| Neighbors - West Neighborhood (the) | 0.1 mi | ★★★★★ | 4 | 0 |
| American Lutheran Home-menomonie | 1.6 mi | ★★★★★ | 5 | 0 |
| Glenhaven | 17.8 mi | ★★★★★ | 18 | 0 |
| Dove Healthcare - West Eau Claire | 18.1 mi | ★★★★★ | 0 | 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.