Below 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 August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Benedictine Manor Of Lacrosse during CMS and state inspections, most recent first.
Failure to prevent and treat pressure injuries: Two residents developed worsening skin breakdown, including one resident with a chronic heel ulcer who developed a new calf wound that progressed to a stage 4 PI while staff did not consistently remove a Rooke Boot, inspect skin, or consult the provider when the wound worsened. Another resident admitted without PIs developed worsening back pressure injuries, with missed weekly wound assessments and progression to an unstageable wound that required antibiotics.
Inadequate supervision for a resident who repeatedly self-transferred and fell. A resident with vascular dementia, impaired memory, and a history of falls was documented as needing 1-assist for transfers and ambulation, yet staff repeatedly observed her self-transferring and self-ambulating despite reminders. She had multiple falls, including one that caused a posterior scalp laceration requiring 2 staples after she grabbed for her walker and fell backwards. The DON stated there was no increased monitoring when she self-ambulated, and staff reported she continued to ambulate independently several times per shift.
Unsafe and unsanitary food service practices were observed when dust was found inside the stove hood on light fixtures and sprinkler heads, staff with facial hair worked without beard restraints, unclean mixers were stored under plastic, a thermometer was sanitized and dried improperly before use, and wet dishware was placed upside down instead of air-dried. The Dietary Manager acknowledged several of these practices did not follow policy.
A facility failed to provide dignified meal assistance when 2 staff were observed helping 6 residents at once, leaving some residents waiting while food sat in front of them. Staff reported they could not sit with residents or converse with them because they were assisting too many people, and leadership stated staff should be seated with residents during feeding. In separate observations, CNAs stood while feeding residents for the entire meal and used clothing protectors as napkins, despite care plans calling for feeding assistance and dignified support.
A resident’s physician/provider did not review the total program of care, including meds and treatments, and monthly orders were not fully signed and dated. Record review showed missing signed monthly orders and a provider note that did not include all orders such as dietary supplements, wound care tx, bladder scans, and tubi grips; the DON and NHA acknowledged the visit note did not cover all orders being reviewed.
A resident receiving hospice services had severe cognitive impairment, lower-extremity impairment, and pressure injuries, but the facility did not establish clear hospice collaboration and communication processes. The DON stated there was no single staff member responsible for reviewing hospice notes or coordinating with hospice, and the resident’s hospice visit notes were not available to direct care or licensed nursing staff.
Infection control practices were not followed for two residents. A resident with COPD and HF developed respiratory symptoms, low O2 sats, and later tested positive for COVID-19 in the ER, but was not tested when symptoms first appeared despite the facility’s symptom-based testing policy. During wound care for another resident with pressure injuries, an RN touched a garbage can with a gloved hand, changed gloves without hand hygiene, and placed treatment supplies in the resident’s wheelchair, contrary to the facility’s hand hygiene policy.
A resident with multiple comorbidities, including vascular dementia, ESRD on dialysis, and diabetes with polyneuropathy, was care planned as dependent for bed mobility and transfers and required Ax2 with a Hoyer lift and Ax2 for ADLs and toileting due to fall risk and generalized weakness. A CNA who was pulled from restorative duties to assist on the unit provided morning toileting cares alone, believing the resident was a one-person assist, without verifying the posted CNA care guide that specified Ax2. While the CNA had the resident rolled onto his side, the resident rolled off the bed, struck a nearby chair, and fell to the floor, sustaining facial cuts and a closed right clavicle fracture confirmed in the ED. The facility’s investigation determined that the fall and injury occurred when the resident’s care plan, requiring two staff for bed mobility, was not followed.
The facility failed to adhere to professional standards for pressure injury care and hand hygiene, affecting three residents. One resident developed a new pressure injury due to inconsistent assessments and delayed interventions. Another resident's care plan was not updated promptly, delaying necessary interventions. Additionally, a nurse did not follow proper hand hygiene during wound care, compromising infection control.
The facility failed to ensure call lights were within reach for four residents, compromising their ability to request assistance. Observations showed call lights were inaccessible for residents with cognitive impairments and mobility issues. Despite staff acknowledging the importance of accessible call lights, no audits or staff education were conducted following a grievance, leading to a deficiency in meeting residents' needs.
The facility failed to maintain proper infection control practices, as staff did not adhere to hand hygiene protocols during medication administration, and a resident's catheter bag was improperly placed on the floor. The DON confirmed the expectations for hand hygiene and catheter care were not met.
A resident with a full code status was found unresponsive, but facility staff delayed CPR initiation, waiting for EMS instructions. Despite the resident's POLST indicating a desire for CPR, the staff did not act immediately, resulting in a deficiency due to the failure to follow advance directives.
Failure to Prevent and Treat Pressure Injuries
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and to prevent new pressure injuries from developing for two residents reviewed for pressure injuries. One resident had a chronic left heel ulcer, was dependent on staff for bed mobility, had diabetes, diabetic neuropathy, and moderate cognitive impairment, and was identified as being at risk for pressure injuries. The resident was placed in a Rooke Boot, but the record did not include instructions for staff on when to remove the boot or how to inspect the skin underneath it. Staff interviews indicated the boot was not consistently removed and skin checks were not reliably completed during care. That resident developed a new left calf pressure injury that progressed from an unstageable wound to a stage 4 pressure injury. Documentation showed the wound enlarged over time, developed necrotic tissue, foul odor, and increasing drainage, including seropurulent drainage, but there was no documentation that the physician was consulted when the wound worsened. Observations also found the resident lying on his back with the left calf resting directly on the mattress without pressure-relieving intervention in place. During wound care observation, staff removed both the heel and calf dressings at the same time, used the same gauze on both wounds, did not perform hand hygiene after touching soiled dressings, did not measure the depth of the calf wound, and placed a wet dressing over intact skin between the wounds. The second resident was admitted without pressure injuries but developed pressure injuries while in the facility, including a mid upper back wound that worsened to an unstageable pressure injury and required antibiotics. Weekly wound assessments were not completed, and the wound was documented over time as changing from blanchable redness to an open area with slough, drainage, necrotic tissue, odor, and worsening size. The resident’s care plan and wound documentation showed ongoing pressure injury concerns, but the record did not show timely facility wound assessments or consistent documentation of the wound’s condition as it deteriorated.
Inadequate supervision for a resident who repeatedly self-transferred and fell
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for a resident with vascular dementia, impaired memory, and a history of self-transferring. The resident’s care plan documented that she required assistance with transfers and ambulation, yet staff repeatedly observed and documented that she self-transferred and self-ambulated despite reminders and education. The record also showed that the resident had an APOAHC, but there was no evidence that the risks and benefits of self-ambulating had been discussed with that representative. The resident experienced multiple falls related to self-transferring. One fall occurred when she was trying to get to the bathroom after being incontinent, and another occurred when she was going to the bathroom and used a tray table as a walker, which broke and caused her to fall. On 5/19/26, a staff member witnessed the resident grab for her walker and fall backwards, striking the back of her head. She sustained a laceration to the posterior scalp that required 2 staples in the emergency department. The fall investigation documented that she was transferring without assistance and that she had a history of self-transferring despite staff reminders and education. The record also showed ongoing self-transferring and wandering behavior after prior falls. Staff notes documented that the resident was found self-transferring to the bathroom, wandering overnight, and entering an unoccupied resident room. Physical therapy documented that she required 1-assist for all transfers and ambulation and that she had poor safety awareness when attempting transfers and ambulation. During interview, the DON stated that the facility did not increase monitoring when the resident self-ambulated, and a CNA stated that the resident ambulated independently 3 to 4 times per shift. The CNA also stated that staff were not doing anything different when they observed her self-ambulating.
Unsafe and Unsanitary Food Service Practices
Penalty
Summary
The facility did not maintain a safe and sanitary environment for food preparation, storage, distribution, and service. On 6/1/26, the surveyor observed dust swinging in the air and suspended from light fixtures inside the stove hood, and the sprinkler heads in the hood were coated with a thin layer of dust. The Dietary Manager and another staff member acknowledged that dust could dislodge and fall into food being prepared underneath. The facility policy on cleaning procedures addressed hood cleaning but did not include the sprinkler system or light fixtures within the stove hood. The surveyor also observed multiple food service practices that did not follow the facility’s policies. Staff with facial hair were working in the kitchen without beard restraints, and one staff member stated he did not know where to find them. Three mixers were stored under plastic covering while still unclean, with dried food particles on the undercarriages, despite policy requiring daily and after-use cleaning before covering. A dietary staff member sanitized a thermometer with an alcohol wipe, then dried it with a paper towel and reused the same wipe before probing another food item. In addition, wet coffee mugs, cups, and dessert bowls were placed upside down on trays, creating a seal and leaving a white film on the dishware instead of allowing them to air dry as required.
Dignity and Respect During Meal Assistance
Penalty
Summary
The facility did not ensure that residents were treated with dignity and respect during assistance with activities of daily living, including dining assistance. Surveyor observation showed 2 staff assisting 6 residents with meals at the same time, with 4 residents waiting for their turn while their plates of food sat in front of them. CNA/Restorative Aide E reported she could not converse with residents or sit alongside them while assisting because she was trying to help too many residents at once. The NHA, RN, and DON each stated that staff should be seated with one or two residents and assist them for the duration of the meal in a dignified manner. R62 had diagnoses including rhabdomyolysis, dementia without behavioral disturbances, moderate protein calorie malnutrition, adult failure to thrive, and cerebrovascular disease. Her care plan directed staff to provide verbal cues, tray setup, pouring liquids, cutting food, applying condiments, and assistance with eating as needed. R24 had dementia and a care plan for setup and supervision assist with feeding, including verbal cues and meal setup. R40 had cerebrovascular disease, hospice, adult failure to thrive, vascular dementia, and disturbances of salivary secretion, and her care plan directed staff to provide assistance with all oral intake as needed and meals in the restorative main dining room. R42 had congenital hydrocephalus and a care plan for total assist with feeding and alternating liquids and solids at a slow rate. R53 had neurocognitive disorder with Lewy bodies, Parkinson's disease, feeding difficulties, and cognitive communication deficit, and her care plan called for feeding assistance or supervision as needed. R61's MDS indicated setup and clean-up assistance with eating. During observation, CNA E assisted R53 while standing for the entire meal and used the clothing protector as a napkin to wipe her mouth. CNA D similarly stood while feeding R42 for the entire meal and used the clothing protector as a napkin throughout the meal. Both CNAs stated they stood to move faster or because it was awkward to feed while seated, and RN C and the DON stated staff should be seated when providing feeding assistance and should use napkins rather than clothing protectors as napkins.
Physician Orders Not Fully Reviewed or Signed
Penalty
Summary
The facility did not ensure the physician or provider reviewed the resident’s total program of care, including medications and treatments, and did not ensure all orders were signed and dated for one resident. Record review showed that R5 was missing signed monthly physician orders for January, February, April, and May of 2026, and the surveyor was unable to locate signed monthly physician orders during the record review on 6/18/26. The surveyor obtained a physician order report dated 2/6/26 to 3/6/26 that was signed by the resident’s provider, and a physician assistant encounter note dated 1/5/26 that did not include all of R5’s orders or total program of care. The note did not include orders for dietary supplements, wound care treatments, bladder scanning, or tubi grips. During interview, the DON stated monthly MD orders are printed for provider rounds and uploaded into the EMAR each month, but acknowledged the visit note did not include all orders being reviewed and that provider visits did not address treatment orders, supplements, blood sugar checks, tubi grips, or bladder scans. The DON and NHA also indicated that all orders should be included in the order review.
Hospice notes were not available to facility staff and no staff member was designated to coordinate hospice care
Penalty
Summary
The facility did not ensure hospice collaboration and communication processes were established to maintain continuity of care between hospice and facility staff for one resident receiving hospice services. The facility policy stated that there should be a designated interdisciplinary team member responsible for coordinating care with hospice representatives and communicating with hospice staff, but the facility did not designate one person for that role. During interview, the DON stated there was no single staff member responsible for reviewing hospice notes; instead, floor nurses reviewed them and shared changes with managers, while managers updated care plans. The resident, R40, had severe cognitive impairment with a BIMS score of 0 out of 15, lower extremity impairments, dependence on staff for rolling in bed, and pressure injury risk with one stage 2 pressure injury and one unstageable pressure injury. The resident’s care plan indicated hospice services for cerebrovascular disease and referenced hospice care plan information in the chart. On survey review of the hospice binder and electronic medical record, the surveyor could not locate hospice nurse notes in either location. When additional documentation was requested, some hospice notes were later provided, but the print date on those notes was 6/3/26. The surveyor also found that R40’s hospice visit notes were not available to the facility’s direct care or licensed nursing staff.
Infection Control Failures During Symptom-Based COVID Testing and Wound Care
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. One resident, who had chronic obstructive pulmonary disease and heart failure, developed respiratory symptoms including pursed lip breathing, oxygen saturation of 85%, shortness of breath, diminished breath sounds, wheezing, rapid shallow respirations, and later cough and low oxygen saturation. The facility’s COVID-19 manual stated that residents with even mild symptoms of COVID-19 should receive viral testing as soon as possible, and the infection prevention nurse and DON both stated that symptomatic residents should be tested right away. Despite this, the resident was not tested for COVID-19 when symptoms first appeared and was later sent to the hospital, where the infection tracker indicated a positive COVID-19 test in the emergency room. A second infection control deficiency occurred during wound care for another resident with pressure injuries to both buttocks. During observed dressing changes, an RN placed one gloved hand on a garbage can, removed that glove, and then put on clean gloves without performing hand hygiene in between. The RN also set treatment supplies in the resident’s wheelchair during the procedure. The facility’s hand hygiene policy required hand hygiene before and after direct resident contact, after removing gloves, and before and after changing a dressing. When interviewed, the RN stated hand hygiene should be performed at the beginning of treatment, between glove changes, when moving from dirty to clean tasks, and at the end of treatment, and acknowledged that hand hygiene should have been done after touching the garbage can and that supplies should not have been placed in the wheelchair. The DON also stated staff should sanitize hands before entering the room, before putting on gloves, between dirty and clean tasks, when exiting the room, and in between working with residents, and agreed that hand hygiene should have been performed after glove removal and that the wheelchair was not an acceptable place for treatment supplies.
Failure to Follow Two-Person Assist Care Plan Resulting in Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan to prevent an accident for one resident at risk for falls. The resident had multiple diagnoses, including vascular dementia (moderate) without behavioral disturbance, end stage renal disease on dialysis, type 2 diabetes with diabetic polyneuropathy, depression, gout, and an acquired absence of the left foot. The resident’s MDS showed he was cognitively intact with a BIMS score of 15. Prior to the fall, his care plan and CNA care guide specified that he was dependent on staff for bed mobility, transfers, and locomotion, and required the assistance of two staff with a full-body Hoyer lift for transfers, as well as assist of two for ADLs and toileting per the mobility care plan. He was also care planned as being at risk for falls due to left-sided and generalized weakness. On the morning of the incident, a CNA who typically worked as a restorative aide was pulled to the hall to help get residents up and went in to assist this resident with morning cares. The CNA rolled the resident onto his left side and was performing toileting cares when the resident rolled off the bed, struck a chair next to the bed, and fell to the floor, landing face down. The CNA reported that she believed the resident was a one-person assist, although the care plan and CNA care guide required two-person assistance for ADLs and bed-related tasks. The CNA acknowledged that care guide sheets for each resident were posted inside the linen closet door on each hallway, that she knew this prior to helping the resident, and that she should have checked the sheet to verify whether another staff member was needed before providing care. Following the fall, nursing staff documented that the resident was found on the floor with facial cuts and was sent to the emergency department for evaluation. The ED record indicated that the resident reported falling out of bed while being assisted with dressing, hitting his head on the floor, and experiencing facial and right shoulder pain. Imaging revealed an equivocal minimally offset fracture of the distal right clavicle, and the ED impression documented a closed right clavicle fracture. The facility’s internal investigation concluded that the resident’s plan of care had not been followed, specifically that the CNA performed bed mobility alone when the resident required two staff for bed mobility, and that this failure to follow the care plan occurred at the time of the fall that resulted in the injury.
Deficiencies in Pressure Injury Care and Hand Hygiene
Penalty
Summary
The facility failed to implement professional standards of practice for pressure injury care, resulting in deficiencies for three residents. Resident 52 was admitted with a stage II pressure injury and was at high risk for developing further injuries. However, the facility did not consistently complete weekly assessments, failed to implement timely interventions, and did not monitor the turning and repositioning program. Additionally, the resident was not educated on the risks and benefits of repositioning, and the physician was not notified when the pressure injury worsened. Consequently, Resident 52 developed a second stage II pressure injury. Resident 49 was admitted with pressure injuries, but the facility did not complete weekly assessments consistently. An air mattress intervention was delayed by eight days after admission. The care plan was not updated promptly to include a pressure-relieving mattress, which was only added eight days after admission, despite the resident having two pressure injuries. For Resident 2, the facility did not adhere to hand hygiene standards during pressure injury wound care. The nurse failed to remove gloves and perform hand hygiene after handling soiled materials and before applying a clean dressing. This lapse in infection control practices was observed during a surveyor's visit, highlighting a deficiency in maintaining proper hand hygiene protocols during wound care procedures.
Deficiency in Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for four residents, leading to a deficiency in meeting the needs and preferences of these residents. Resident 18, who has moderate cognitive impairment and requires assistance with mobility, was observed with the call light out of reach while sitting in a recliner. Similarly, Resident 2, who is cognitively intact but requires supervision due to a non-weight bearing condition, had the call light on the floor, making it inaccessible. Resident 9, with moderate cognitive impairment and needing assistance with personal hygiene, had the call light placed on a bedside stand behind them, out of reach. These observations indicate a failure to adhere to the facility's policy of ensuring call lights are accessible to residents. Additionally, a grievance was filed regarding Resident 29's call light being out of reach, but no findings or actions were documented in the grievance log. Interviews with staff, including CNAs and the DON, confirmed that call lights should always be accessible to residents. However, no audits or spot checks were conducted following the grievance, and no staff education was provided to address the issue. This lack of action further contributed to the deficiency in ensuring residents' call lights were within reach, compromising their ability to request assistance when needed.
Infection Control Deficiencies in Hand Hygiene and Catheter Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations of staff not adhering to hand hygiene protocols and improper handling of a catheter bag. During medication administration, a registered nurse did not perform hand hygiene after taking vital signs for one resident and before administering insulin to another. This was contrary to the facility's hand hygiene policy, which requires hand hygiene before and after direct resident contact and after removing gloves. The Director of Nursing confirmed that the expectation is for hand hygiene to be performed between each resident interaction. Additionally, a resident's catheter bag was observed hanging from a garbage can and resting on the floor, which is not in compliance with the facility's policy on preventing catheter-associated urinary tract infections. The policy emphasizes the importance of proper catheter care to prevent complications such as cystitis and septic shock. A certified nursing assistant acknowledged that the placement of the catheter bag was unacceptable and took immediate action to correct it. The Director of Nursing confirmed that the catheter bag should not be on the floor.
Failure to Follow Advance Directives for CPR
Penalty
Summary
The facility failed to adhere to a resident's advance directives regarding their code status, resulting in a deficiency. The resident, who had a Physician Orders for Life Sustaining Treatment (POLST) indicating a desire for Cardiopulmonary Resuscitation (CPR), was found unresponsive, without respirations or a pulse. Despite the clear indication for CPR, the facility staff did not initiate resuscitation efforts immediately upon discovering the resident's condition. The incident involved a resident with a complex medical history, including end-stage renal disease, hypertension, and type 2 diabetes mellitus, among other conditions. The resident was found by a Registered Nurse (RN) kneeling on the floor with a grayish skin tone, indicating a lack of circulation. The RN confirmed the resident's full code status but delayed CPR initiation, opting to wait for Emergency Medical Services (EMS) instructions instead. The delay in initiating CPR lasted at least seven minutes from the time the resident's full code status was confirmed until EMS arrived and began resuscitation efforts. This delay was attributed to a lack of immediate action and delegation of duties among the staff, as noted by the Nursing Home Administrator and Director of Nursing. The facility's policy was not followed, leading to a finding of immediate jeopardy due to the failure to provide timely life-saving measures.
Removal Plan
- The facility completed crash cart audits, including nightly checks and weekly verification by DON B.
- The facility completed code status and POLST/POST audits for all facility residents.
- The facility reviewed/audited advance directives/care plans for all facility residents.
- The facility audited all in-house licensed staff on their CPR certifications.
- The facility provided all in-house licensed staff education, including RN D and RN E on the following: Facility CPR policy, Nurse response and initiation of CPR for residents with a full-code status, EMS activation, POLST/POST and code status location/verification, Crash cart location, Delegation of duties, CPR situational review.
- The facility provided all staff (except licensed staff) with education on roles and responsibilities during a CODE.
- Mock code competency audits were conducted on various shifts.
- Crash cart audits start and will continue beyond.
- Documentation of the completion of education for RN D and RN E following R1's incident.
- Education for all staff.
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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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Illustrative
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Nursing homes near La Crosse
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverside | 0.8 mi | ★★★★★ | 12 | 0 |
| Bethany St Joseph Care Ctr | 1.1 mi | ★★★★★ | 0 | 0 |
| Hillview Health Care Ctr | 1.3 mi | ★★★★★ | 15 | 0 |
| La Crescent Health Services | 5.2 mi | ★★★★★ | 25 | 1 |
| Onalaska Care Center | 7.2 mi | ★★★★★ | 1 | 0 |
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