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 Bethany St Joseph Care Ctr during CMS and state inspections, most recent first.
Nutrition services staff with visible facial hair were observed monitoring hot foods in the kitchen without wearing beard restraints, contrary to state regulations and facility policy. This failure to properly cover facial hair during food preparation and service had the potential to affect all 68 residents.
Surveyors found that the facility did not have an infection prevention and control program in place, resulting in a lack of measures to prevent and control infections among residents and staff.
A resident with significant medical conditions and limited ROM did not receive the prescribed restorative nursing program after therapy services ended. The restorative plan, which included use of a Nu-step machine, was not implemented due to lack of documentation in the appropriate section of the Kardex and lack of awareness among CNAs, resulting in the resident not receiving necessary maintenance services.
A resident with a neurogenic bladder and indwelling Foley catheter had the catheter changed every 90 days on a fixed schedule, despite facility policy and standards requiring changes only for clinical indications. Staff and the DON confirmed there was no documented rationale for the scheduled changes, resulting in a deficiency.
A resident requiring dialysis did not receive pre- and post-dialysis assessments, including vital signs and port site checks, as required by facility policy and standard practice. Staff interviews confirmed that communication with the dialysis unit was inconsistent and that a communication binder was not used. The DON acknowledged these practices did not meet facility standards.
A resident with hypertension, renal failure, and diabetes with neuropathy had increased edema in bilateral lower extremities. The physician ordered Furosemide and daily weights for two weeks, followed by weekly weights. The facility failed to follow the order, recording weights only on three occasions out of the required fourteen-day period. The DON acknowledged the failure and indicated that a Performance Improvement Plan was initiated, but the order was not followed through by the CNAs.
The facility failed to ensure appropriate hand hygiene during wound care for two residents, leading to deficiencies in infection control practices. Staff did not perform hand hygiene after removing gloves and before donning new ones, contrary to facility policy and CDC guidelines.
The facility failed to follow Enhanced Barrier Precautions (EBP) and proper hand hygiene protocols. CNAs did not wear gowns during high-contact care for a resident with a urinary catheter, and another CNA did not perform hand hygiene between glove changes during personal care tasks.
Failure to Use Beard Restraints During Food Preparation
Penalty
Summary
Surveyors observed that nutrition services staff with facial hair were not wearing beard restraints while monitoring the temperature of hot foods in the kitchen. Specifically, one staff member had facial hair on the chin measuring approximately 1.5 inches long by 2 inches wide, and another had facial hair extending from in front of the ears down to the chin, both visibly long and dark. The facility's dress code policy required beard guards for facial hair longer than 1/2 inch, but state regulations and the WI Food Code require all facial hair to be covered, regardless of length. These observations indicated that food was not being stored, prepared, distributed, and served in accordance with professional standards designed to prevent foodborne illness, potentially affecting all 68 residents in the facility.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, as the facility did not have an established or operational program to prevent and control infections among residents and staff. The absence of such a program was directly observed and documented by surveyors.
Failure to Implement Restorative Nursing Program for Resident with Limited ROM
Penalty
Summary
A resident with multiple medical conditions, including chronic pulmonary embolism, mild cognitive impairment, depression, history of intracranial hemorrhage, osteoporosis, acute respiratory failure, and type 2 diabetes mellitus with chronic kidney disease, was identified as having limited range of motion (ROM) in one upper extremity and both lower extremities. The resident required maximum assistance with dressing, hygiene, and all movement, and was wheelchair dependent. The facility's policy required that residents with limited ROM receive appropriate restorative nursing services to maintain or prevent further reduction in ROM. However, the resident's restorative plan, which included use of a Nu-step machine three times per week, was not implemented after therapy services ended. The resident reported that therapy had stopped and was unsure of the reason, while the Rehab Director confirmed the resident was no longer on the therapy caseload and was supposed to be on a restorative program instead. Interviews and record reviews revealed that the restorative order was not documented in the appropriate section of the resident's Kardex, and CNAs were unaware of the restorative program for the resident. The section of the Kardex designated for restorative programs was blank, and there was no evidence of CNA documentation or charting to show that the restorative plan was being carried out. The Director of Nursing acknowledged that the restorative order was in the wrong section and not being implemented, and the resident did not receive the maintenance program as intended.
Routine Catheter Changes Without Clinical Indication
Penalty
Summary
A deficiency was identified when a resident with a history of neurogenic bladder and urinary retention, who had an indwelling Foley catheter, received catheter changes on a fixed 90-day schedule without documented clinical indication. The facility's policy and professional standards require that indwelling catheters and drainage bags be changed only when clinically indicated, such as in cases of infection, obstruction, or compromise of the closed system, and not at routine, fixed intervals. However, the resident's treatment administration record showed that the Foley catheter was changed every 90 days per physician order, but there was no supporting documentation in the medical record to justify this scheduled change. During interviews, both a registered nurse and the Director of Nursing confirmed that the catheter was being changed on a scheduled basis, and the DON acknowledged that there was no documented rationale for this practice. The lack of clinical justification for routine catheter changes was inconsistent with both facility policy and current standards of practice, leading to the deficiency.
Failure to Provide Pre/Post Dialysis Assessments and Communication
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for a resident with end stage renal disease who was dependent on renal dialysis. Specifically, the facility did not ensure ongoing assessment of the resident's condition or monitoring for complications before and after dialysis treatments, as required by both facility policy and professional standards of practice. Review of the resident's treatment administration record and nursing notes revealed that dialysis port assessments and vital signs were not completed prior to or after dialysis treatments. There was also no order entered for the frequency of vital sign monitoring, and the facility did not use a communication binder to facilitate information exchange with the dialysis unit. Interviews with facility staff, including a nurse tech, RN, and the DON, confirmed that pre/post dialysis assessments and communication binders were not consistently used for the resident. Staff indicated that communication with the dialysis unit was informal and not standardized, and that vital signs were only taken weekly or at the dialysis unit itself. The resident also reported that port site assessments and vital sign checks were not performed before or after dialysis, and that communication with the dialysis unit was sporadic. The DON acknowledged that these practices did not align with facility policy or standard of care.
Failure to Follow Physician Orders for Daily Weights
Penalty
Summary
The facility did not ensure that a resident received treatment and care in accordance with professional standards of practice. A resident admitted with diagnoses of hypertension, renal failure, and diabetes with neuropathy was noted to have increased edema in bilateral lower extremities. The physician ordered Furosemide and daily weights for two weeks, followed by weekly weights. However, the facility failed to follow the physician's order for daily weights, recording weights only on three occasions out of the required fourteen-day period. The Director of Nursing acknowledged the failure and indicated that a Performance Improvement Plan was initiated, but the order was not followed through by the certified nursing assistants.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility did not ensure appropriate hand hygiene during wound care for two residents, leading to deficiencies in infection control practices. For one resident with severe cognitive impairment and multiple medical conditions, including a stage 4 pressure injury, the Licensed Practical Nurse (LPN) failed to perform hand hygiene after removing gloves and before donning new ones multiple times during the dressing change. This included handling wound dressings and applying ointments without sanitizing hands between glove changes, which is against the facility's hand hygiene policy and CDC guidelines. In another instance, a Registered Nurse (RN) performed wound care for a resident with multiple diagnoses, including severe protein-calorie malnutrition and chronic kidney disease. The RN did not perform hand hygiene after removing gloves and before donning new ones during the dressing change. This failure occurred despite the RN's acknowledgment that hand hygiene should be performed before and after the start and stop of wound care, as well as after each glove change. Interviews with the involved staff and the Director of Nursing (DON) confirmed that the expectation for hand hygiene was not met. The DON and the wound care nurse both stated that hand hygiene should be performed after each glove change, highlighting a lapse in adherence to infection control protocols during wound care procedures for these residents.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility did not maintain an infection prevention and control program according to professional standards of practice. Specifically, Enhanced Barrier Precautions (EBP) with appropriate Personal Protective Equipment (PPE) were not followed for a resident with a urinary catheter. During an observation, two Certified Nursing Assistants (CNAs) performed personal care for the resident without wearing gowns, despite the facility's policy and CDC guidelines requiring gowns and gloves for high-contact activities such as catheter care. Interviews with staff, including Registered Nurses (RNs) and the Director of Nursing (DON), confirmed that the expectation was to wear gowns and gloves during direct care for residents on EBP, which was not adhered to in this instance. Additionally, the facility failed to follow proper hand hygiene protocols during personal care for another resident. A CNA was observed conducting various personal care tasks, including handling soiled incontinence pads and applying lotion, without performing hand hygiene between glove changes. The facility's policy mandates handwashing before and after resident care and after removing gloves. The CNA admitted to not performing hand hygiene during the care process, and the DON confirmed that the expectation was to conduct hand hygiene after completing incontinence care and removing gloves.
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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 La Crosse
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hillview Health Care Ctr | 1 mi | ★★★★★ | 15 | 0 |
| Benedictine Manor Of Lacrosse | 1.1 mi | ★★★★★ | 1 | 0 |
| Riverside | 1.8 mi | ★★★★★ | 12 | 0 |
| La Crescent Health Services | 6.2 mi | ★★★★★ | 25 | 1 |
| Onalaska Care Center | 8 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.