Benedictine Manor of LaCrosse

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

46.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 69 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 63.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 30 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.34 therapist hours per resident per day in 2026Q1 — more than 58% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 80 beds and averages 60.4 residents a day — about 76% occupied, or roughly 20 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.56 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.04 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.22 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.28 hrs/resident/day on weekends vs 3.68 on weekdays — 11% thinner on weekends. RN hours go from 1.12 to 0.82 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 49% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

25 citations, most serious first. The 17 most serious are shown; the remaining 8 are one tap away and print in full.

• Immediate jeopardy · Jcited before2026-06-18 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. When the pressure injury showed signs of worsening, the physician was not consulted to determine if there was a need to change treatments. Observations found that R5 would lie on his back with the left calf resting directly on the mattress without pressure relieving devices in place. In addition, wound care…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2024-06-11 · tag F0678 — failed to provide CPR when needed — isolated
  Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. The facility took steps on [DATE], immediately after the incident, to correct the deficient practice and to ensure compliance. The immediate jeopardy was removed on [DATE] and corrected on [DATE]. Based on this determination,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Actual harm · Gcited before2026-06-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  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. Evidenced by:The facility policy and procedure, Integrated Fall Management, undated, documents in part, as follows: Purpose: Fall risk assessment, identification, and implementation of appropriate interventions as necessary, to maintain resident safety, prevent falls and reduce further injury from falls. Policy: Residents are assessed for their risk of falls…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-01-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. R1 admitted to the facility on [DATE] and has diagnoses that include, in part: acquired absence of left foot, vascular dementia (moderate) without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (cognitive…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Actual harm · Gcited before2025-03-05 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 worsened. R52 developed a second stage II PI on 3/4/25. This example is being cited at actual harm. R49 was admitted to the facility with PIs. Weekly assessments were not completed consistently and the intervention of air mattress was…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-01-11 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon interview, policy review and record review, the facility did not ensure allegations of abuse and neglect were thoroughly investigated or prevent further potential abuse from occurring while the investigation was in progress for 1 of 1 (R270) resident reviewed. R270 alleged CNA N put her fingers up R270's rectum. R270 experienced recurring fear and anxiety, expressed by feeling tense, nervous and fearful of CNA N when CNA N came to her room after this incident. This is evidenced by: The facility's policy and procedure for Abuse Prevention, last reviewed 07/21/22, includes, in part: The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, or mistreatment. This will be done by: * All allegations of abuse will be thoroughly investigated by the Director of Social Services, Director of Nursing. Measures will be taken to identify the source of the alleged abuse and prevent future incidents. * Identify and interview all who might know about…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-10-25 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that residents are free of significant medication errors for 6 of 8 residents (R1, R9, R11, R12, R13, and R10) reviewed for medication errors. R1's medication error resulted in actual harm. R1's prophylactic antibiotic was discontinued when a nurse entered new orders for Spirolactone on 7/13/23. Per interview and record review it is unclear why the nurse discontinued the antibiotic. R1 was then hospitalized on [DATE] for spontaneous bacterial peritonitis (SBP; a serious infection of the fluid that fills the abdomen) due to not receiving her prescribed prophylactic antibiotic resulting in significant medication error. R9's dosing of Lorazepam was decreased from 0.5 mg to 0.25 mg. Pharmacy sent a card of the 0.5 mg Lorazepam and staff continued to give that dose without noting the dose difference. R11's Gabapentin was transcribed with an end date of 8/20/23 and should have been open ended with no stop date. The discrepancy was noted and fixed on…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2026-06-18 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 59 residents who reside in the facility.Surveyor observed dust covering the sprinkler heads and suspended from the light fixtures in the facility's stove hood.Surveyor observed staff with facial hair and not wearing hair restraints.Surveyor observed [NAME] J use a dirty alcohol swab to sanitize a thermometer and intervened before the thermometer touched resident food. Surveyor also observed [NAME] J use a dry paper towel to manually dry the thermometer after sanitizing it and before probing food.Surveyor observed 3 mixers to be stored under a plastic covering and unclean.Surveyor observed staff placing wet dishware upside down on trays creating a seal and not allowing the dishware to airdry completely.Evidence by:Example 1Facility policy, titled Cleaning Procedures, undated, includes: Hoods and filters- Clean inside and outside of hood. Wash hood with detergent solution. the interior…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-06-18 · tag F0550 — failed to protect resident dignity and rights — pattern
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not ensure that every resident was treated with dignity and respect when providing activities of daily living for 3 of 18 residents (R24, R40, R42) reviewed and 3 supplemental residents (R53, R62, R61). Surveyor observed 2 staff assisting 6 residents with their meal. 4 residents were made to wait until their turn to receive dining assistance while their plate of food sat on the table in front of them. CNA/Restorative Aide E kept getting up to assist at two different tables and reported that she is not able to converse with residents and sit alongside them while she assists them with dining, because of how many she is trying to assist. R42 was not assisted with her meal in a dignified and home-like manner. R53 was not assisted with his meal in a dignified and home-like manner. Evidenced by: Facility's admission Packet, undated, includes: . Every facility resident has the right to be treated as an individual with courtesy, respect, and dignity.…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-06-18 · tag F0711 — isolated
  Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review the facility did not ensure the Physician or Provider, reviewed the resident's total program of care, including medications and treatments or sign and date all orders for 1 of 1 Residents Physician orders reviewed (R5). R5 was missing a provider review of R5's total program of care, including medications and treatments due to not having signed monthly orders for January, February, April and May of 2026 Evidenced by: Facility policy entitled, Physician Services, indicates the following: Procedure: .11. The physician will: a. review the resident's total program of care, including medications and treatments, at each visit; b. Write, sign and date progress notes at each visit; and c. sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved facility standing house orders after an assessment for contraindications. On 6/18/26 Surveyor conducted record review and was not able to locate signed monthly physician orders. Surveyor asked for R5's signed monthly physician orders for…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-06-18 · tag F0849 — isolated
  Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure hospice collaboration and communication processes were established to ensure continuity of care between hospice and the facility for 1 of 1 resident (R40) reviewed for hospice. R40's hospice notes are not available to facility staff. The facility did not designate a staff member to coordinate the plan of care with the hospice provider. As evidenced by: The facility policy entitled, Hospice, dated June 2021, states, in part: .Policy: The community will provide collaborative care with Hospice providers to ensure the resident's end of life preferences and choices are honored . Procedure 1. There is agreement for the provision of hospice services with one or more Medicare-certified hospices. 2. This signed agreement will include. i. A provision that the community associates are responsible for the administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care. 4. There…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-06-18 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 21 residents (R65 and R1) reviewed for infection control. R65 was not tested for COVID-19 after he was showing signs and symptoms of COVID-19. RN M (Registered Nurse) did not complete hand hygiene during R1's wound care. This is evidenced by: The facility's COVID-19 manual, dated 9/29/22, includes Symptom-and Contact-Based Testing: Test vaccinated and unvaccinated residents and associates (1) who develop COVID-19 symptoms. For symptom-based testing, anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for SARS-CoV-2 as soon as possible. R65 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (a progressive lung…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-03-05 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
  Reasonably accommodate the needs and preferences of each resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure call lights were in reach for 2 of 15 sampled residents (R) (R18 and R2) and 2 of 2 supplemented residents (R9 and R29). R18, R2, and R9 were observed to not have their call lights within reach On 2/26/25, a grievance was filed regarding R29's call light not being within reach. Evidenced by: The facility's call lights - Call System Activation and Response Policy dated 2024, includes, in part, Purpose: The purpose of this procedure is to ensure timely responses to residents' requests and needs. Residents are provided with a means to call for staff assistance through a communication system that directly notifies a staff member or a centralized workstation. Procedure: 1. Each resident is provided with a means to call staff directly for assistance. The call system must be accessible to residents while in bed or other sleeping accommodations withing the resident's room. Example 1 R18 was admitted to the facility on [DATE]. R18's diagnoses…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-03-05 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 of 5 care observations (R209, R49 and R210). Staff did not perform hand hygiene before putting on gloves when passing medications for R210 and R49. R209's catheter bag was hanging from the garbage can and lying on the floor. Findings: Example 1 Facility policy titled, Hand Hygiene revised date of 9/2023, stated in part: Infection Prevention begins with the basic hand hygiene. By following proper hand hygiene practices, associates will reduce the spread of potentially deadly germs, as well as reduce the risk of healthcare provider colonization caused by germs acquired from the resident .Times to Perform Hand Hygiene are, but not limited to: * Before or after direct resident contact . * Before or after assisting a resident with personal cares . * Upon and after coming in contact with a resident's intact…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2024-01-11 · tag F0880 — failed to prevent and control infections — widespread
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect all 63 residents. The facility did not have a clear water management process or plan in effect to prevent transmission of Legionella infection. The facility staff did not use appropriate Personal Protective Equipment (PPE) when entering COVID-positive isolation rooms on contact/droplet precautions residents (R) (R272, R49, and R41); and did not ensure shared medical equipment is properly sanitized. Staff did not keep clean linens stored in the linen rooms on all halls free from contamination of possible infections. Improper hand hygiene was observed during medication administration for R30 and R47. Findings include: The facility policy entitled, Water Management program for building…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-01-11 · tag F0755 — failed to provide safe pharmacy services — pattern
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record review and interview, the facility did not ensure all drugs and biologicals were securely stored for 5 of 5 residents (R) (R56, R25, R41, R30, and R9) and did not ensure controlled drugs were stored in separately locked, permanently affixed compartments. The facility did not ensure drugs and biologicals were labeled with an expiration date in accordance with currently accepted professional principles for 1 of 1 resident (R) (R272). Findings include: Surveyor requested and reviewed the facility policy titled Hazardous waste pharmaceuticals/Disposal dated 2020. The policy in part reads: Products to be disposed of in the DEA receptacle include pills, tablets, capsules, ointment creams, lotions, powders, liquid medications, expired drugs, and all partial medications regardless of expiration status. It is suggested to keep all expired or no longer-in-use medications in a secure location, i.e., code-protected drop-down bin receptacle, until disposal. These receptacles are transported off-site by the vendor according to EPA guidelines . Example 1 On 01/10/24 at…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-01-11 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility did not ensure they were monitoring the effectiveness of psychotropic drugs. Behavioral monitoring was not completed as outlined in the comprehensive care plan to determine effectiveness of the medication for 4 of 5 residents (R) reviewed. (R29, R46, R30, and R47) Findings include: Example 1 R29 was admitted on [DATE] and has diagnoses that include, dementia, adjustment disorder with mixed anxiety and depression, and type 2 diabetes. R29's Minimum Data Set (MDS), indicated that R29 has a Brief Interview for Mental Status (BIMS) of 07 which indicates that R29 is severely impaired. R29's care plan, with an approach start date of 07/21/23 reads in part monitor behavior every shift and document. On 01/10/24 at 2:25 PM, Surveyor interviewed Certified Nursing Assistant (CNA) E and asked where CNA's complete behavior monitoring would be located. CNA E indicated there was a binder at the nurse's station. Surveyor asked to see behavior monitoring for the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$90,784 in federal fines across 5 penalties.

• $12,438 — penalty dated 2026-01-21
• $24,382 — penalty dated 2025-03-05
• $10,036 — penalty dated 2024-06-11
• $30,275 — penalty dated 2024-01-11
• $13,653 — penalty dated 2023-10-25

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to BENEDICTINE HEALTH SYSTEM — 23 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 10 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $693K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in WI