Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 - East Neighborhood (the) during CMS and state inspections, most recent first.
The facility did not maintain complete documentation of COVID-19 vaccine education, offering, and current vaccination status for staff, and no specific COVID-19 vaccination policy was provided. Survey review found that staff were mainly notified by email about vaccine clinics, while formal education was only given to staff who attended a meeting or completed consent forms. Several staff interviewed stated they did not receive education at the facility and did not sign declinations, and the facility’s records did not show education for all staff or complete declination documentation.
The facility did not maintain an effective infection prevention and control program. A CNA handled soiled laundry without a gown or other clothing barrier and wore the same soiled scrubs while sorting and washing linens. During resident care, one CNA performed catheter and peri care without removing gloves or completing hand hygiene while touching multiple clean and contaminated items, and another CNA continued care with contaminated gloves, handling a gait belt, wheelchair parts, glasses, and the resident before leaving the room without hand hygiene.
The facility failed to provide required transfer/discharge notices and complete bed-hold information for two residents. One resident had multiple hospitalizations without a transfer notice, and the bed-hold notices lacked the daily private-pay rate. Another resident’s ER transfer notice did not state the specific reason for transfer/discharge or reserve payment information. Staff also reported that an Ombudsman notification was not sent for one hospitalization.
Failure to Ensure Follow-Up Dental Care: A resident with intact cognition repeatedly reported broken teeth, pain with eating, and a request for extractions and dentures, but the facility did not document follow-up on the dental provider’s recommendations or explain the delay. Records showed a dental assessment and later notes about poor oral intake and weight loss tied in part to poor dental status, while staff described only verbal/email communication and no clear documentation trail for the referral process.
A resident with severe cognitive impairment alleged sexual abuse, but staff failed to perform a full body and peri area skin assessment as required by facility policy. Only the resident's arm was checked after the allegation, and interviews confirmed that a comprehensive assessment was not completed.
The facility's Infection Control Program was found lacking, with incomplete surveillance and infection control logs, inadequate tracking of symptomatic residents and staff, and failure to implement Enhanced Barrier Precautions (EBP) for residents with specific conditions. Staff did not consistently sanitize equipment or perform proper hand hygiene, contributing to the deficiency.
Two residents with dementia were not treated with dignity during meal assistance. A CNA stood over a resident with Alzheimer's and used a spoon and clothing protector to clean the resident's mouth instead of a napkin. Another CNA stood over a resident with Lewy Body dementia while assisting with a meal. These actions compromised the residents' dignity and respect.
A facility failed to accurately code the MDS assessment for a resident with schizophrenia, dementia, and anxiety. Although a PASARR level 2 screen was completed, the MDS assessments incorrectly indicated it was not. The social worker responsible acknowledged the error during an interview.
A resident with chronic obstructive pulmonary disease and atherosclerotic heart disease was not provided with respiratory care consistent with professional standards. The resident's oxygen tubing, which was supposed to be changed every 5 days per physician's orders, had not been changed for over three weeks. The tubing on the portable oxygen tank was also not dated, and a nurse confirmed the oversight.
Incomplete COVID-19 Vaccine Education and Documentation for Staff
Penalty
Summary
The facility did not maintain documentation of screening, education, offering, and current COVID-19 vaccination status for staff. Survey review found no policy specifically addressing COVID-19 vaccination for residents or staff in the documents provided, which included policies for antibiotic stewardship, infection surveillance, influenza prevention, influenza vaccination, pneumococcal vaccine, and the pandemic plan. The report states the facility did not develop and implement policies and procedures regarding COVID-19 immunization, and the staff vaccination listing did not identify whether education had been provided. During interviews, the Assistant Clinical Mentor stated the pharmacy comes to provide the COVID-19 vaccine to staff who want it, and that staff are sent a message when the clinic is scheduled. She stated education is provided when staff complete the consent and if they ask, and that the facility does not require staff to sign a declination every year if they do not want the vaccine. The Clinical Mentor stated that only staff on the roster received formal education before receiving the vaccine, and that staff who were not at the meeting only received the email about the clinic and not the education. The Matrix messages reviewed showed notice of the clinic and that consent forms were available, but no education attachments or embedded education materials were included. Record review and staff interviews showed incomplete documentation for staff vaccination status and declinations. The surveyor reviewed the most recent COVID-19 consent or declination records for three nursing staff members and found vaccination dates in the records, but no declinations since those dates. Two nurses stated they had not received education about the benefits or side effects of the COVID-19 vaccine and had not signed declinations, while another staff member stated she received the email about the vaccine but not education at the facility and had declined. A homemaker stated she received education elsewhere and only got an email that the vaccine was being offered at the facility. The facility also provided a meeting sign-in sheet and two slides on COVID-19 and flu season, but attendance was limited and did not show that all staff received education.
Infection Control Lapses During Laundry and Resident Care
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection. Housekeeping staff did not use any type of clothing barrier, such as an apron, when sorting and washing dirty laundry, and improper hand hygiene was observed during catheter care and personal care for two residents. The report states this practice had the potential to affect all 16 residents residing in the same household. During laundry observations, CNA E collected a resident’s soiled laundry without gloves, gown, or other PPE, dumped a garbage bag of laundry into a 3-compartment hamper cart, and transported the cart to the laundry room. In the laundry room, CNA E put on gloves only, leaned into the soiled linen cart without a gown or protective barrier, and her scrub top touched the cart while she pulled out soiled items. CNA E transferred resident clothing and unit towels into the washer while wearing the same soiled scrub top and stated she did not use any other PPE besides gloves. The laundry room contained a sink for handwashing and a disposable plastic gown/apron hanging on the wall, and CNA E acknowledged that a gown should have been worn. During morning care for a resident with an indwelling urinary catheter, CNA E performed peri care and catheter care while wearing the same gloves throughout multiple tasks. Without removing gloves or performing hand hygiene, CNA E handled the urinary leg bag, disconnected and reconnected catheter tubing, cleaned the catheter connection, continued peri care, touched the resident’s socks, towel, incontinent product, pants, bed controller, and urinary bag, and completed additional catheter bag care. CNA E later stated the expectation was to remove gloves and perform hand hygiene after peri care. In a separate observation, CNA F provided care to another resident, washed the resident’s face, back, arms, and peri area, then continued with contaminated gloves to handle the gait belt, wheelchair brakes, the resident’s glasses, and wheelchair handles, and transported the resident out of the room without completing hand hygiene. CNA F later stated gloves should have been removed and hands sanitized before the resident was transferred to the wheelchair.
Missing transfer notices and bed-hold details
Penalty
Summary
The facility did not ensure residents or their representatives received required written notice of the bed-hold policy and transfer/discharge information for two residents. For one resident, the facility did not provide a transfer notice form for hospitalizations on 07/09/25, 07/19/25, and 07/23/25, and the bed-hold notices for the 07/19/25 and 07/23/25 hospitalizations did not include the daily payment rate. For the other resident, the discharge notice for the 12/06/25 transfer to the emergency room did not state the specific reason for transfer/discharge and did not identify any reserve payment on the bed-hold notice. Surveyor review of the electronic health record showed one resident was hospitalized for shortness of breath, coughing, a resident request to transfer to the ER, an unwitnessed fall, and tachycardia. During interview, the Assistant Clinical Mentor stated a Notice of Transfer was not available for the 07/19/25 transfer and explained that nurses are sometimes in a hurry and it does not always happen. The Social Worker stated there was no bed hold or notice of transfer for the 07/09/25 hospitalization because the resident returned within 4 hours, and also stated she did not know the updated regulation regarding the daily payment rate on the bed-hold notice. The Social Worker further stated she did not know the Ombudsman should have been notified for the 07/19/25 hospitalization because the resident was in the hospital only for 4 hours.
Failure to Ensure Follow-Up Dental Care
Penalty
Summary
The facility did not ensure follow-up dental care for a resident who complained of tooth pain and requested extraction of his remaining teeth because broken teeth were causing pain while eating. The resident’s cognition was intact, with a BIMS score of 15 out of 15, and he reported that he had asked for help arranging a dental appointment so his teeth could be pulled and he might eat better. Surveyor observation noted the resident hiding his teeth and appearing worried about his smile, and he stated, “My teeth are broken and hurts when eating sometimes.” Record review showed a dental referral and assessment history, including a specialty referral for the resident to have the rest of his teeth pulled and a later dental assessment documenting that he wanted teeth extracted and dentures. The dental assessment noted oral cancer screening was negative and discussed treatment options, including saving teeth or considering other options, with the resident choosing affordable dentures. A dietary note later documented poor oral intake, slow weight loss over years, and that the resident cited poor dental status as a factor affecting eating. Despite these documented concerns and the resident’s repeated requests, the facility did not have documentation of follow-up on the dental provider’s recommendations or documentation explaining extenuating circumstances for the delay. Staff interviews indicated the request was discussed verbally and by email, but the unit clerk reported no paper trail because she did not have EHR access, and the facility could not produce verification of the referral request or follow-up documentation. Interviews also showed staff uncertainty about responsibility for tracking outside dental recommendations, and the resident’s dental needs remained unresolved in the record reviewed.
Failure to Complete Full Body Assessment After Sexual Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse for one resident with severe cognitive impairment. The resident, who had diagnoses including dementia with anxiety, generalized anxiety disorder, and chronic kidney disease, reported being sexually assaulted by a man. The facility's policy required an immediate full body skin assessment to be completed and documented by the nursing supervisor in such cases. However, after the allegation was made, only the resident's arm was assessed by the DON and nurse practitioner, as the resident mentioned arm pain. No full body or peri area skin assessment was performed or documented, despite the policy and the nature of the allegation. Interviews with staff confirmed that a comprehensive skin assessment was not completed. The LPN stated that no full body assessment was done, and the DON acknowledged that, in hindsight, a full assessment should have been performed. The facility did notify law enforcement and the resident's POA, and the resident was interviewed by the social worker, but the investigation lacked the required thorough physical assessment to check for signs of trauma or injury related to the alleged abuse.
Inadequate Infection Control Program and Practices
Penalty
Summary
The facility failed to establish an effective Infection Control Program, which is crucial for investigating, controlling, and preventing infections among residents and staff. The program lacked a comprehensive system for recording incidents and implementing corrective actions in a timely manner. The facility did not utilize a data collection tool for early detection of symptomatic residents and staff, which is essential for identifying, tracking, and monitoring possible communicable diseases and outbreaks. During a COVID outbreak, the facility's line lists were incomplete, failing to document critical information such as the start date, type of symptoms, and resolved dates. Additionally, the facility did not conduct adequate surveillance monitoring for residents and staff prior to the outbreak. The facility's infection control logs from September 2023 to August 2024 were not fully completed, missing essential details like room numbers, resolved dates, symptoms, diagnostic results, and the type of cautionary measures implemented. The infection preventionist acknowledged the lack of daily surveillance documentation and indicated that changes in residents' conditions were only reported during morning meetings. Staff illnesses were not adequately tracked, and there was no systematic approach to monitor staff for potential outbreaks. The infection preventionist admitted that more detailed surveillance was necessary to effectively identify, prevent, and control the spread of infections. Specific instances of non-compliance with infection control practices were observed. Staff failed to sanitize equipment, such as a Hoyer lift, after resident use, and did not perform proper hand hygiene during dressing changes. Enhanced Barrier Precautions (EBP) were not implemented for residents with conditions requiring such measures, including those with indwelling catheters and a history of MRSA. The facility's policy on EBP had not been updated to reflect recent CMS guidelines, resulting in a lack of appropriate precautions for residents with chronic conditions that necessitate additional protective measures.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, which compromised their quality of life. Specifically, two residents with dementia, who were unable to advocate for themselves, were observed being assisted with meals in a manner that lacked dignity. One resident, diagnosed with Alzheimer's and dementia, required a mechanically altered diet and was dependent on others for meal assistance. A Certified Nursing Assistant (CNA) was observed standing over this resident and using a spoon and the resident's clothing protector to clean food from around the resident's mouth instead of using a napkin. This behavior was observed multiple times during a lunch observation. Another resident, diagnosed with Lewy Body dementia and memory deficit following a cerebral infarction, required setup or cleanup assistance while eating. A different CNA was observed standing over this resident while assisting with the meal. These actions were deemed to make a reasonable person feel inferior or vulnerable, thus failing to honor the residents' rights to dignity and respect.
MDS Coding Error for PASARR Level 2 Screen
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident reviewed for Preadmission Screening and Resident Review (PASARR) screen. The resident, who was admitted with diagnoses including schizophrenia, dementia, and anxiety, had a PASARR level 2 screen completed on 05/06/24. However, the resident's admission MDS assessment dated 05/14/24 and significant change MDS assessment dated 07/26/24 incorrectly indicated that no PASARR level 2 screen had been completed. During an interview, the social worker responsible for completing the MDS Section A1500 acknowledged the error, stating it was a mistake on their part, despite the PASARR level 2 screen being present in the records.
Failure to Change Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident requiring continuous oxygen. The resident, who has chronic obstructive pulmonary disease and atherosclerotic heart disease, was observed with oxygen tubing that had not been changed as per the physician's order, which specified a change every 5 days. On observation, the oxygen tubing connected to the concentrator was dated 9/1, indicating it had not been changed for over three weeks. Additionally, the portable oxygen tank's tubing was not dated, and the registered nurse confirmed the tubing had not been changed according to the physician's orders.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 91 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 - West Neighborhood (the) | 0 mi | ★★★★★ | 4 | 0 |
| Neighbors - Central Neighborhood (the) | 0.1 mi | ★★★★★ | 0 | 0 |
| American Lutheran Home-menomonie | 1.7 mi | ★★★★★ | 5 | 0 |
| Glenhaven | 17.9 mi | ★★★★★ | 18 | 0 |
| Dove Healthcare - West Eau Claire | 18.1 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Neighbors - East Neighborhood (the).
100% money-back within 48 hours.
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.