Benedictine Manor of Lacrosse
2902 East Avenue South, La Crosse, WI 54601 · La Crosse County · 80 certified beds · avg 60 residents/day · certified since Oct 1, 1989
Part of chain: BENEDICTINE HEALTH SYSTEM (23 facilities, chain avg rating 2.8★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Jun 18, 2026 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jul 16, 2026 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Jun 11, 2024 · F-0678 · triggered by a complaint
The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes.
Why it matters: In a cardiac or breathing emergency, failure to start CPR promptly can be the difference between life and death.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: May 17, 2024 (Past Non-Compliance)
▲ Actual harm, one-off · Jun 18, 2026 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 16, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jan 21, 2026 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jan 6, 2026 (Past Non-Compliance)
▲ Actual harm, one-off · Mar 5, 2025 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 25, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jan 11, 2024 · F-0610 · triggered by a complaint
The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do.
Why it matters: When allegations aren't investigated, harm to residents can continue unchecked.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Feb 6, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 25, 2023 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Nov 20, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (25)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 18, 2026 | ▲ J · Immediate jeopardy, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Jun 18, 2026 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jun 18, 2026 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Jun 18, 2026 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Jun 18, 2026 | D · Potential for harm, one-off | The facility did not make sure the resident's doctor reviewed their care and wrote, signed, and dated progress notes and orders at each required visit. · from a complaint |
| Jun 18, 2026 | D · Potential for harm, one-off | The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life. · from a complaint |
| Jun 18, 2026 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Jan 21, 2026 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Mar 5, 2025 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Mar 5, 2025 | E · Potential for harm, repeated | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Mar 5, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jun 11, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes. · from a complaint |
| Jan 11, 2024 | ▲ G · Actual harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Jan 11, 2024 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jan 11, 2024 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Jan 11, 2024 | E · Potential for harm, repeated | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Jan 11, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Jan 11, 2024 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Jan 11, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jan 11, 2024 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Oct 25, 2023 | ▲ G · Actual harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Dec 8, 2022 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Dec 8, 2022 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Dec 8, 2022 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Dec 8, 2022 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (8 → 3).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 4 | 0 | F |
| 2023 | 1 | 1 | G ▲ |
| 2024 | 9 | 2 | J ▲ |
| 2025 | 3 | 1 | G ▲ |
| 2026 | 8 | 3 | J ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
5 fines totaling $90,784.
| Date | Type | Amount / length |
|---|---|---|
| Jan 21, 2026 | Fine | $12,438 |
| Mar 5, 2025 | Fine | $24,382 |
| Jun 11, 2024 | Fine | $10,036 |
| Jan 11, 2024 | Fine | $30,275 |
| Oct 25, 2023 | Fine | $13,653 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Wisconsin avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.89 | 4.29 | 3.95 | bottom 42% in Wisconsin; top 44% in the U.S. |
| Registered Nurse hours | 1.13 | 1.01 | 0.69 | top 33% in Wisconsin; top 11% in the U.S. |
| Weekend total nurse staffing | 3.59 | 3.84 | 3.50 | bottom 45% in Wisconsin; top 38% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.82 | 0.68 | 0.48 | top 25% in Wisconsin; top 11% in the U.S. |
| Total nursing staff turnover (%) | 49.4 | 46.9 | 45.8 | bottom 42% in Wisconsin; bottom 38% in the U.S. |
| RN turnover (%) | 47.4 | 39.7 | 42.9 | bottom 38% in Wisconsin; bottom 40% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.56, RN 1.04, weekend 3.28. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 2/5 · short-stay residents: 4/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Benedictine Health System | Organization | 5% or Greater Indirect Ownership Interest | 100% | 10/01/2012 |
| Catholic Residential Services INC | Organization | 5% or Greater Direct Ownership Interest | 100% | 01/01/1966 |
| Benedictine Health System | Organization | Operational/Managerial Control | NOT APPLICABLE | 10/01/2012 |
| Bergien, Tricia | Individual | Corporate Officer | NOT APPLICABLE | 10/27/2016 |
| Bowe, Tia | Individual | Corporate Director | NOT APPLICABLE | 10/31/2019 |
| Bruhn, Jennifer | Individual | Corporate Director | NOT APPLICABLE | 07/01/2022 |
| Carley, Gerald | Individual | Corporate Director | NOT APPLICABLE | 01/23/2018 |
| Nykiel, Christine | Individual | Corporate Director | NOT APPLICABLE | 10/01/2012 |
| Rymanowski, Kevin | Individual | Corporate Director | NOT APPLICABLE | 01/23/2014 |
| Thompson, Leslie | Individual | Contracted Managing Employee | NOT APPLICABLE | 12/30/2019 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "Are staff on every shift trained and certified in CPR, and how do they know each resident's resuscitation wishes?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "How often does each resident's doctor visit and review their care in person?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Riverside | 0.8 mi | La Crosse, WI | ★★★★☆ | 4/5 | |
| Bethany St Joseph Care Ctr | 1.1 mi | La Crosse, WI | ★★★★☆ | 3/5 | |
| Hillview Health Care Ctr | 1.3 mi | La Crosse, WI | ★★★★★ | 4/5 | |
| La Crescent Health Services | 5.2 mi | La Crescent, MN | ★☆☆☆☆ | 1/5 | |
| Onalaska Care Center | 7.2 mi | Onalaska, WI | ★★★★★ | 5/5 | |
| Mulder Health Care Facility | 11.4 mi | West Salem, WI | ★☆☆☆☆ | 1/5 | |
| Lakeview Health Center | 11.5 mi | West Salem, WI | ★★★★★ | 4/5 | |
| Valley View Healthcare & Rehab | 16.6 mi | Houston, MN | ★★★★★ | 4/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 525438.