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
Staffing
Hours and turnover
RN hours / resident day
1.13
Registered nurse staffing
LPN hours / resident day
0.28
Licensed practical nurse staffing
Aide hours / resident day
2.27
Nurse aide staffing
Weekend hours
3.22
Weekend nurse staffing
RN turnover
41%
Annual RN turnover
Total nurse turnover
52%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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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