Above average — CMS composite of the measures below.
The next survey window likely opens around February 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 Neighbors - West Neighborhood (the) during CMS and state inspections, most recent first.
A resident with vascular dementia, agitation, and anxiety received PRN lorazepam for anxiety, but the order was not limited to 14 days and lacked a documented rationale for extended use or a specific duration. The MAR showed repeated use of the medication, and the DON stated the order was missed getting the continued order.
The facility did not adequately address repeated falls for two residents with significant fall risk, impaired cognition, and mobility limitations. One resident with Parkinsonism and osteoporosis sustained an unwitnessed fall that later resulted in a wrist fracture, but no new safety interventions were implemented and the care plan was not updated. Another resident with dementia, hemiplegia, and multiple unwitnessed room falls had several incidents where the resident slid from bed or fell near the recliner; some events had no new interventions and no documentation that bed or recliner equipment was checked for safety or function.
A resident with multiple pain-related diagnoses and scheduled and PRN analgesic orders did not receive adequate pain assessment or documentation. Staff repeatedly gave PRN pain meds without recording pain intensity, location, or characteristics, did not use the ordered non-pharmacological intervention of ice/cold compress, and did not document provider notification or alternative measures when scheduled topical analgesic doses were refused. Interviews showed nursing staff were unsure how to assess pain consistently or choose among PRN options, while the MD and DON described expectations for using non-opioid measures first and documenting pain details.
Hand hygiene was not consistently performed during resident cares. A CNA changed gloves without cleaning hands while providing morning care and catheter care to cognitively intact residents, and another CNA continued care with contaminated hands during morning care for a resident with dementia and rheumatoid arthritis, including transfers, grooming, and feeding preparation. The DON acknowledged the missed hand hygiene, and the CNA stated hand hygiene should have been done between glove changes and before the resident ate.
A resident with a skin injury did not receive comprehensive weekly wound assessments as required by the facility's policy. Despite having a treatment order for weekly documentation, the facility failed to perform consistent assessments, particularly after the resident returned from the hospital with a wound vac order. The Director of Nursing stated that the facility does not measure surgical wounds weekly, contributing to the deficiency in care.
The facility failed to implement effective infection control measures, as evidenced by the lack of Enhanced Barrier Precautions for a resident with a diabetic ulcer and improper PPE use for another resident with a wound infection. Staff did not adhere to hand hygiene protocols, and equipment was not properly disinfected. Additionally, a staff member was observed wearing a mask incorrectly during a period of heightened precautions.
PRN Lorazepam Order Lacked Required Duration and Rationale
Penalty
Summary
A resident with diagnoses including vascular dementia with agitation and anxiety was prescribed PRN lorazepam for anxiety on 02/27/26, but the order was not limited to 14 days and did not include a specific duration for use or a documented rationale for extended use. The physician order directed lorazepam 0.25 mg orally every 4 hours PRN for anxiety, with instructions to monitor response and consider an alternative if ineffective, and the MAR showed the medication was administered repeatedly on 02/27/26, 02/28/26, 03/01/26, 03/02/26, 03/04/26, 03/06/26, 03/07/26, and 03/09/26. Review of the medical record did not locate documentation supporting continued PRN psychotropic use beyond the initial period, and the DON stated the facility works with hospice and tries not to have PRN psychotropic medications, adding that this order was missed getting the continued order.
Failure to address repeated resident falls and revise fall interventions
Penalty
Summary
The facility did not ensure the resident environment remained free of accident hazards as possible and did not provide adequate supervision and assistive devices to prevent accidents for two residents who had repeated falls. The report states that R11 and R35 both had fall histories, and the facility did not initiate immediate interventions to prevent future falls, investigate the root cause of the falls, or review and revise fall-related care plans as needed. The facility policy required fall risk assessment, interventions, documentation, regular reassessment, discussion of falls at morning meetings, and review of residents with multiple falls for trends. R11 was admitted with Parkinsonism, anxiety disorder, and age-related osteoporosis, had moderately impaired cognition, impaired range of motion, substantial/maximal assistance needs for ADLs, and a history of a fall with major injury. After an unwitnessed fall in the resident's room, R11 was later found to have right wrist pain, swelling, and bruising, and was diagnosed with a right radius fracture. The facility identified the root cause as self-transferring without assistance, but no new safety interventions were implemented and the care plan was not updated. The DON stated that appropriate safety interventions were already in place and no changes were needed. R35 was admitted with hemiplegia and hemiparesis following cerebral infarction, dementia with agitation, anxiety and mood disorder, major depressive disorder, insomnia, polyneuropathy, and overactive bladder, and had moderately impaired cognition with substantial/maximal assistance needs for some transfers and mobility. R35 experienced multiple unwitnessed falls in the room, including falls from or near the bed and recliner, with repeated documentation that the resident slid off the bed, crawled out of bed, or fell while attempting to reach items or use the recliner. Some incidents resulted in care plan updates, but several falls had no new safety interventions and no documentation that the bed, recliner, or other equipment was assessed for safety and functioning. The DON stated that no new interventions were necessary because the facility was not responsible for preventing falls, only injuries, and R35 had not sustained injuries from the falls.
Inadequate Pain Assessment and Management
Penalty
Summary
The facility did not adequately assess and provide pain management services for one resident who required such care. The resident had diagnoses including Parkinsonism, panic disorder, disorientation, generalized anxiety disorder, polyneuropathy, lumbar disc degeneration with discogenic back pain, and a brain stimulator implant. The resident’s admission MDS showed a BIMS score of 13/15, indicating cognition intact, and the resident received scheduled pain medication. The care plan identified potential pain/discomfort related to the right shoulder and directed staff to administer pain relief measures, evaluate and document effectiveness, and use appropriate pain scales and non-therapeutic interventions as needed. The resident had multiple pain-related medication orders, including PRN acetaminophen, PRN tramadol, scheduled meloxicam, topical diclofenac gel for right shoulder pain, topical muscle rub, and ice/cold compresses for the right shoulder. The PRN orders did not include clear parameters or indications for when each medication should be used. Survey review of the MAR showed repeated PRN administrations for pain, but the documentation did not include pain severity, location, or characteristics for many of the doses. Several entries documented only "pain" or a general body area, and first-time reports of pain in new locations such as the right hip, right lower rib, and right lower quadrant were not accompanied by documentation of provider notification. The resident’s follow-up PRN pain assessments also did not include intensity, severity, or characteristics of pain. The ordered non-pharmacological intervention of ice/cold compress was not administered at any time during the review period. In addition, the scheduled Voltaren gel was documented as refused on numerous occasions, but there was no documentation of provider notification, pain assessment, or alternative interventions associated with those refusals. During interview, an RN stated pain scores were not typically documented unless a MAR prompt appeared, location and characteristics were not typically assessed, and there was no known standard for choosing among multiple PRN pain medications. The RN also stated he was unaware of the ordered non-pharmacological intervention. The MD stated nursing staff were expected to use non-opioid measures first, evaluate efficacy, and then determine whether opioid medication should be used. The DON stated pain assessments should include a pain score or face scale, that PRN documentation should include location and severity if a score could not be entered, that non-pharmacological interventions should be used first, and that the provider should be notified when a resident refuses scheduled pain medication.
Hand Hygiene Not Performed During Resident Cares
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program designed to maintain a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections during observed resident cares. During morning care for a cognitively intact resident with acute cystitis with sepsis, a CNA performed hand hygiene on entry and used PPE for Enhanced Barrier Precautions, but then touched clothing items, drawers, and the resident during care, removed soiled gloves, and put on clean gloves multiple times without performing hand hygiene between glove changes. The DON later stated the CNA should have performed hand hygiene in between glove changes. During urinary catheter care for a cognitively intact resident with urine retention, a CNA again changed gloves without hand hygiene between glove changes while providing care, including emptying the catheter. During morning care for a resident with dementia and rheumatoid arthritis who was dependent on staff for personal hygiene, a CNA sanitized hands on entry, provided care, removed gloves without hand hygiene, and continued with contaminated hands while assisting the resident with transfers, clothing, footwear, and grooming. The CNA did not wash the resident's hands before breakfast, and later stated hand hygiene should have been completed when gloves were removed and the resident's hands should have been sanitized before eating.
Failure to Conduct Comprehensive Wound Assessments
Penalty
Summary
The facility failed to complete comprehensive weekly wound assessments for a resident, identified as R30, who had a skin injury. The facility's policy required weekly wound documentation, but this was not adhered to for R30. The resident, who had an open wound on the left lower leg, was admitted to the facility with several diagnoses, including osteoporosis and Alzheimer's disease. An event report documented that R30 developed a skin tear on the left calf, which was initially treated but later required emergency care due to bleeding and exposure of fatty tissue. Despite the facility's treatment order form specifying weekly measurements and documentation for wounds, R30's wound assessments were not conducted comprehensively or consistently. The resident returned from the hospital with a wound vac order, but the facility did not perform a comprehensive wound assessment upon readmission. The first documented comprehensive assessment occurred a week later, and no further assessments were completed for the rest of December. The next assessment was not until four weeks later, and it lacked details on the wound's depth and drainage. The Director of Nursing (DON) indicated that the facility does not perform weekly measurements for surgical wounds, which they considered R30's wound to be. The DON acknowledged that the resident frequently scratched at the wound, which could have contributed to the infection. However, the facility's failure to conduct regular and comprehensive wound assessments as per their policy and treatment orders led to a deficiency in providing appropriate care for R30's wound.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed by surveyors. One resident with a diabetic foot ulcer did not have Enhanced Barrier Precautions (EBP) initiated, despite facility policy and CDC recommendations indicating that EBP should be implemented for residents with chronic wounds. The Director of Nursing (DON) acknowledged the need for EBP for such conditions but did not initiate it for the resident, relying instead on personal experience and training, which was not aligned with the facility's policy. Another resident, who was on EBP due to a wound infection with multidrug-resistant organisms, did not receive proper care from the staff. Certified Nursing Assistants (CNAs) and a Registered Nurse (RN) failed to wear the required personal protective equipment (PPE) such as gowns and gloves during high-contact care activities. Additionally, hand hygiene practices were inadequate, as observed when a CNA did not wash hands properly between glove changes. The RN also used contaminated scissors to cut a new dressing for the resident's wound, further compromising infection control. The facility's infection control practices were further compromised by the improper disinfection of equipment. Slings used for resident transfers were not disinfected after each use, increasing the risk of cross-contamination. Additionally, a staff member was observed wearing a mask incorrectly during a time when the facility had implemented masking as a preventative measure following an outbreak. These observations indicate a systemic failure in adhering to infection control protocols, as outlined in the facility's policies and CDC guidelines.
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Illustrative
What surveyors actually found near you
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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 mi | ★★★★★ | 5 | 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 |
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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.