Benedictine Manor of LaCrosse

In the surveyor’s words

From the most serious findings on record at Benedictine Manor of LaCrosse, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Jun 18, 2026

  Based on interviews, observations, and record reviews, the facility failed to ensure that 2 of 3 residents (R5 and R40) reviewed for pressure injuries out of a total sample of 21, received care to prevent the development of pressure injuries and/or promote the healing of existing pressure injuries.R5 had a chronic left heel ulcer and was at risk for the development of additional pressure injuries. The facility implemented a Rooke Boot but did not include interventions for staff to follow related to removal of the boot. Staff interviews found that staff did not consistently remove the boot and/or did not complete a thorough skin inspection with cares. R5 developed a stage 4 pressure injury to the left calf. […]

• Immediate jeopardy, isolatedF678Jun 11, 2024

  Based on interview and record review, the facility failed to have a system in place to ensure the code status of residents (R), as indicated in the advance directives, is followed. This affected 1 of 1 resident reviewed (R1) whose Cardiopulmonary Resuscitation (CPR) wishes were not followed. R1's Physician Orders for Life Sustaining Treatment (POLST) indicated R1 wanted CPR. The facility failed to initiate CPR upon finding R1 with no respirations and pulseless. The facility's failure to follow the code status identified in the advance directives and failure to begin cardiopulmonary resuscitation created a finding of immediate jeopardy that began on [DATE]. The Nursing Home Administrator (NHA) A and Director of Nursing (DON) B were notified of the immediate jeopardy on [DATE] at 1:55 p.m. […]

• Actual harm, isolatedF689Jun 18, 2026

  Based on interview and record review, the facility failed to ensure each resident receives adequate supervision to prevent accidents for 1 of 5 residents (R21) reviewed for accidents.R21 self-transferred and fell backwards while grabbing for her walker, hitting her head. Subsequently, R21 sustained a laceration to the back of her head that required staples. CNA K (Certified Nursing Assistant) stated to Surveyor that R21 ambulates independently 3-4 times each shift. There is no evidence that risks and benefits associated with self-ambulating have been discussed with R21's APOAHC (Activated Power of Attorney for Health Care.) There is no evidence of increased monitoring to prevent further self-ambulation and potential injuries. […]

• Actual harm, isolatedF689Jan 21, 2026

  Based on interview and record review, the facility did not ensure staff provided adequate supervision to prevent an accident for 1 of 4 residents reviewed for falls (R1). R1 sustained a fall from bed on 1/6/26, resulting in a closed right clavicle (collarbone) fracture after a certified nursing assistant (CNA) failed to follow R1's care plan, which required the assistance of two staff members for cares. CNA C performed R1's morning cares on her own.This is evidenced by: Facility policy titled Integrated Fall Management, effective 8/24/17, states in part, .Policy: Residents are assessed for their risk of falls upon admission, significant change and quarterly thereafter. Residents with risk for falling will have interventions implemented through the resident centered care plan. […]

• Actual harm, isolatedF686Mar 5, 2025

  Based on observation, interview, and record review, the facility did not implement professional standards of practice to ensure that a resident does not develop pressure injuries (PIs), receives necessary treatment and services to promote healing and prevent infection of PIs, or prevent new PIs from developing for 3 of 6 residents (R) reviewed for pressure injuries (R52, R49, R2). R52 was admitted to the facility with a stage II PI and determined to be at high risk for PI. Weekly assessments were not completed consistently, implementing interventions to prevent/improve PIs was not timely, turning and repositioning program was not monitored/reviewed, R52 was not educated on risk vs benefits of repositioning and offloading to prevent/improve PI, and physician was not notified when PI… […]