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 July 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.
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 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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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 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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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.