Benedictine Manor Of Lacrosse

Penalties

• 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)

Inspection findings

1. Jun 18, 2026 Health · 7 findings
   • Not serious Scope/severity E Complaint

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Jul 16, 2026 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Jul 16, 2026 · CMS health inspection

   • Serious Scope/severity G Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jul 16, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0711 Nursing and Physician Services Deficiencies

     Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

     Corrected Jul 16, 2026 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Jul 16, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0849 Administration Deficiencies

     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.

     Corrected Jul 16, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jul 16, 2026 · CMS health inspection

2. Jan 21, 2026 Health · 1 finding
   • Serious Scope/severity G Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jan 6, 2026 · CMS health inspection

3. Mar 5, 2025 Fire Safety · 14 findings
   • Not serious Scope/severity F

     E0006 Emergency Preparedness Deficiencies

     Conduct risk assessment and an All-Hazards approach.

     Corrected Mar 25, 2025 · CMS fire safety

   • Not serious Scope/severity E

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Mar 25, 2025 · CMS health inspection

   • Serious Scope/severity G

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Mar 25, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Mar 25, 2025 · CMS health inspection

   • Not serious Scope/severity D

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Apr 4, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0331 Smoke Deficiencies

     Construct fire resistant interior walls.

     Corrected Mar 25, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0343 Smoke Deficiencies

     Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.

     Corrected Apr 4, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0351 Smoke Deficiencies

     Install an approved automatic sprinkler system.

     Corrected Mar 25, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Apr 4, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     Corrected Mar 25, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0912 Gas, Vacuum, and Electrical Systems Deficiencies

     Have power receptacles that are properly grounded.

     Corrected Mar 25, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Mar 25, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0919 Gas, Vacuum, and Electrical Systems Deficiencies

     Meet requirements for the use of electrical equipment.

     Corrected Mar 25, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Mar 25, 2025 · CMS fire safety

4. Jun 11, 2024 Health · 1 finding
   • Serious Scope/severity J Complaint

     F0678 Quality of Life and Care Deficiencies

     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 May 17, 2024 · CMS health inspection

5. Jan 11, 2024 Health · 10 findings
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Feb 6, 2024 · CMS health inspection

   • Serious Scope/severity G Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Feb 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0644 Resident Assessment and Care Planning Deficiencies

     Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

     Corrected Feb 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Feb 6, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Feb 6, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0758 Pharmacy Service Deficiencies

     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 Feb 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Feb 6, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Feb 6, 2024 · CMS health inspection

   • Not serious Scope/severity F

     K0232 Egress Deficiencies

     Have corridors or aisles that are unobstructed and are at least 8 feet in width.

     Corrected Feb 6, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Feb 6, 2024 · CMS fire safety

6. Oct 25, 2023 Health · 1 finding
   • Serious Scope/severity G Complaint

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Nov 20, 2023 · CMS health inspection

7. Dec 8, 2022 Health · 8 findings
   • Not serious Scope/severity D

     F0554 Resident Rights Deficiencies

     Allow residents to self-administer drugs if determined clinically appropriate.

     Corrected Jan 17, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0761 Pharmacy Service Deficiencies

     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 Jan 17, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Jan 17, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jan 17, 2023 · CMS health inspection

   • Not serious Scope/severity D

     K0223 Egress Deficiencies

     Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

     Corrected Jan 17, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jan 17, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Jan 17, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Feb 28, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• BERGIEN, TRICIA — corporate officer, NOT APPLICABLE, since 10/27/2016
• BOWE, TIA — corporate director, NOT APPLICABLE, since 10/31/2019
• BRUHN, JENNIFER — corporate director, NOT APPLICABLE, since 07/01/2022
• CARLEY, GERALD — corporate director, NOT APPLICABLE, since 01/23/2018
• NYKIEL, CHRISTINE — corporate director, NOT APPLICABLE, since 10/01/2012
• RYMANOWSKI, KEVIN — corporate director, NOT APPLICABLE, since 01/23/2014
• THOMPSON, LESLIE — contracted managing employee, NOT APPLICABLE, since 12/30/2019
• BENEDICTINE HEALTH SYSTEM — operational/managerial control, NOT APPLICABLE, since 10/01/2012
• BENEDICTINE HEALTH SYSTEM — 5% or greater indirect ownership interest, 100%, since 10/01/2012
• CATHOLIC RESIDENTIAL SERVICES INC — 5% or greater direct ownership interest, 100%, since 01/01/1966