Benedictine Manor of Lacrosse

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that services provided by the facility meet professional standards of quality for 1 of 5 residents (R50) reviewed for unnecessary medications. R50 is receiving Melatonin for insomnia and did not have a sleep assessment/tracking completed. Findings Include:R50 admitted to the facility on [DATE] and has the following diagnoses: Insomnia, Chronic congestive heart failure, Type 2 Diabetes Mellitus, Anxiety disorder, Major Depressive Disorder, and mild cognitive impairment. R50's physician orders include, in part: Melatonin 3 mg at bedtime. Take one tablet by mouth at bedtime for sleep. On 6/3/2026 at 3:17 PM, DON B (Director of Nursing) indicated she was not able to find a completed sleep assessment for R50. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased on interview and medical record review, the facility did not ensure to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 21 sampled residents (R50). R50 was noted to drop a pill while she was taking oral medications. The pill was never recovered, the other pills were swallowed, and it was unknown which medication was omitted. The facility failed to monitor R50 following the omission and failed to contact R50's Medical Doctor. Evidenced by:Facility policy, titled Medication Error/Occurrences, includes: 8/31/23, includes: When an error is made in the preparation or administration of a medication or a mediation error is discovered the licensed nurse is notified. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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).

Inspectors wroteBased 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)

Inspectors wroteBased on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when an allegation of abuse was not reported immediately but not later than 2 hours after the allegation is made, to the administrator of the facility and to other officials for 1 of 1 resident reviewed for abuse. (Resident (R) 270)

Inspectors wroteBased on interview and record review, the facility did not refer a resident with serious mental disorders for a Level II Preadmission Screen and Resident Review (PASRR), after the resident's stay was extended past 30 days; this occurred for 1 of 1 resident (R46). Findings Include: R46 was admitted to the facility on [DATE] with diagnoses that include major depressive disorder, anxiety disorder, and post-traumatic stress disorder. R46 has a Brief Interview for Mental Status (BIMS) score of 15, which means they are cognitively intact. On 01/09/24 at 7:23 AM, record review of R46's current PASRR one indicated that no level two was required due to the exemption of being in the facility for 30 days or less. R46 has been a resident since 4/25/23 and is currently a resident in the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure resident (R270) needing care and treatment of constipation received the services to ensure an adequate bowel regimen for 1 of 12 residents reviewed.

Inspectors wroteBased on record review and interview, the facility did not ensure they maintained medical records on each resident that are complete and accurately documented in accordance with accepted professional standards and practices and have them readily accessible for Surveyors to review for 1 of 3 residents (R61) reviewed for closed records. This is evidenced by: On 01/10/24, Surveyor requested 3 closed records from Nursing Home Administrator (NHA) A. On 01/11/24, Surveyor reviewed the electronic medical record for R61. R61 was admitted to the facility on [DATE] from [Name] Health System. R61 had Do Not Resuscitate orders. R61 was found to be unresponsive at the facility on 12/15/23. [...]

Inspectors wroteBased 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. [...]