Cycle 1
Health 2025-03-05 · Fire 2025-03-05
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
La Crosse, WI
Benedictine Manor Of Lacrosse
3-star overall rating with 3-star inspections with $78,346 in total fines with 4 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
2902 East Avenue South, La Crosse, WI
(608) 788-9870
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
60
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Benedictine Health System
Operator or chain grouping
Approved since
1989-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
22 facilities
Chain averages 3 overall / 3 health / 4 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.13
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.28
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.27
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.68
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.41
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.22
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.92
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.25
CMS adjusted RN staffing hours
Adjusted total hours
4.06
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
41%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,140
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.69
Composite VBP score used to determine payment impact.
Payment multiplier
0.9847
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.52
Baseline 18.52% · Performance 20.26% · Measure score 2.52 · Achievement 2.52 · Improvement 0
Healthcare-associated infections
3.67
Baseline 6.64% · Performance 6.74% · Measure score 3.67 · Achievement 3.67 · Improvement 0
Total nurse turnover
2.27
Baseline 62.07% · Performance 54.41% · Measure score 2.27 · Achievement 2.27 · Improvement 1.56
Adjusted total nurse staffing
2.62
Baseline 3.81 hours · Performance 3.82 hours · Measure score 2.62 · Achievement 2.62 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.19% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 81 · Observed rate 9.88% · Lower 95% interval 7.09% |
| Discharge to community | 46.2% |
50.57%
4.4 pts worse
|
No Different than the National Rate · Eligible stays 69 · Observed rate 39.13% · Lower 95% interval 34.76% |
| Medicare spending per beneficiary | 0.73 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 31 · Denominator 31 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 31 |
| Discharge self-care score | 68% |
53.69%
14.3 pts better
|
Numerator 17 · Denominator 25 |
| Discharge mobility score | 48% |
50.94%
2.9 pts worse
|
Numerator 12 · Denominator 25 |
| Pressure ulcers or injuries, new or worsened | 9.68% |
2.29%
7.4 pts worse
|
Numerator 3 · Denominator 31 · Adjusted rate 9.11% |
| Healthcare-associated infections requiring hospitalization | 6.74% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 27 · Observed rate 3.7% · Lower 95% interval 3.51% |
| Staff COVID-19 vaccination coverage | 4.76% |
8.2%
3.4 pts worse
|
Numerator 5 · Denominator 105 |
| Staff flu vaccination coverage | 29.55% |
42%
12.4 pts worse
|
Numerator 52 · Denominator 176 |
| Discharge function score | 64% |
56.45%
7.5 pts better
|
Numerator 16 · Denominator 25 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.6
0.9 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.7 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
2.2
1.3 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.4% |
95.7%
0.3 pts worse
|
93.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.7% · Q2 93.8% · Q3 95.9% · Q4 94.5% · 4Q avg 95.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.1% |
95.0%
1.1 pts better
|
95.5%
0.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.2% |
3.2%
3 pts worse
|
3.3%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 4.2% · Q3 8.2% · Q4 9.1% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
5.0%
4.4 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents who lose too much weight | 2.4% |
4.9%
2.5 pts better
|
5.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.6% · Q3 2.4% · Q4 2.1% · 4Q avg 2.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.0% |
16.6%
4.6 pts better
|
19.6%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 10.5% · Q3 11.9% · Q4 12.2% · 4Q avg 12.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 28.2% |
16.7%
11.5 pts worse
|
16.7%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.1% · Q2 30.0% · Q3 30.6% · Q4 25.0% · 4Q avg 28.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 19.8% |
21.1%
1.3 pts better
|
16.3%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.2% |
17.3%
5.9 pts worse
|
14.9%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.4% · Q2 28.6% · Q3 17.9% · Q4 17.4% · 4Q avg 23.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.3%
2.3 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.1% |
3.0%
1.1 pts worse
|
1.7%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.1% · Q3 8.2% · Q4 3.8% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.1% |
25.5%
6.6 pts worse
|
19.8%
12.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.3% · Q2 34.0% · Q3 23.1% · Q4 45.0% · 4Q avg 32.1% |
| Percentage of long-stay residents with pressure ulcers | 10.5% |
5.5%
5 pts worse
|
5.1%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 17.2% · Q3 11.9% · Q4 4.2% · 4Q avg 10.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
86.8%
11 pts better
|
81.7%
16.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.3% · Q2 97.4% · Q3 100.0% · Q4 100.0% · 4Q avg 97.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 0.0% |
15.0%
15 pts better
|
12.0%
12 pts better
|
Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.3% |
82.2%
0.1 pts better
|
79.7%
2.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.5% |
22.7%
3.8 pts worse
|
23.9%
2.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.5% · Observed 25.0% · Expected 22.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-11 · Fire 2024-01-11
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-12-08 · Fire 2022-12-08
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-05
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-03-25
F · Potential for more than minimal harm
2025-03-05
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-03-25
E · Potential for more than minimal harm
2025-03-05
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-03-25
E · Potential for more than minimal harm
2025-03-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-04
E · Potential for more than minimal harm
2025-03-05
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-03-25
E · Potential for more than minimal harm
2025-03-05
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-03-25
E · Potential for more than minimal harm
2025-03-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-03-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-05
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-03-05
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-03-25
F · Potential for more than minimal harm
2024-01-11
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-02-06
E · Potential for more than minimal harm
2024-01-11
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-02-06
F · Potential for more than minimal harm
2022-12-08
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-02-28
D · Potential for more than minimal harm
2022-12-08
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-01-17
D · Potential for more than minimal harm
2022-12-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-17
D · Potential for more than minimal harm
2022-12-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-17
Inspection history
Recent health citations
G · Actual harm
2026-01-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-01-06
G · Actual harm
2025-03-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-25
E · Potential for more than minimal harm
2025-03-05
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-03-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-25
J · Immediate jeopardy
2024-06-11
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-05-17
G · Actual harm
2024-01-11
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-02-06
F · Potential for more than minimal harm
2024-01-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-06
E · Potential for more than minimal harm
2024-01-11
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-02-06
E · Potential for more than minimal harm
2024-01-11
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-02-06
D · Potential for more than minimal harm
2024-01-11
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-02-06
D · Potential for more than minimal harm
2024-01-11
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-02-06
D · Potential for more than minimal harm
2024-01-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-06
D · Potential for more than minimal harm
2024-01-11
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-02-06
G · Actual harm
2023-10-25
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-11-20
F · Potential for more than minimal harm
2022-12-08
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-01-17
E · Potential for more than minimal harm
2022-12-08
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-01-17
E · Potential for more than minimal harm
2022-12-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-17
D · Potential for more than minimal harm
2022-12-08
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-01-17
Penalties and ownership
What sits behind the stars
$24,382
2025-03-05
Fine
Fine · fine $24,382
Fine
$10,036
2024-06-11
Fine
Fine · fine $10,036
Fine
$30,275
2024-01-11
Fine
Fine · fine $30,275
Fine
$13,653
2023-10-25
Fine
Fine · fine $13,653
Fine
Ownership
Benedictine Health System
5% Or Greater Indirect Ownership Interest · Organization
Catholic Residential Services Inc
5% Or Greater Direct Ownership Interest · Organization
Benedictine Health System
Operational/Managerial Control · Organization
Bergien, Tricia
Corporate Officer · Individual
Bowe, Tia
Corporate Director · Individual
Bruhn, Jennifer
Corporate Director · Individual
Carley, Gerald
Corporate Director · Individual
Nykiel, Christine
Corporate Director · Individual
Rymanowski, Kevin
Corporate Director · Individual
Thompson, Leslie
Contracted Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Riverside
La Crosse, WI
5-star overall rating with 4-star inspections with $21,645 in total fines with 3 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Bethany St Joseph Care Ctr
La Crosse, WI
4-star overall rating with 3-star inspections with $3,145 in total fines with 6 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Hillview Health Care Ctr
La Crosse, WI
4-star overall rating with 3-star inspections with $15,593 in total fines with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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