Benedictine Manor of Lacrosse

Quality of Life and Care Deficiencies

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

Quality of Life and Care Deficiencies

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

Emergency Preparedness Deficiencies

Conduct risk assessment and an All-Hazards approach.

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the use of electrical equipment.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

Smoke Deficiencies

Install an approved automatic sprinkler system.

Smoke Deficiencies

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

Gas, Vacuum, and Electrical Systems Deficiencies

Have power receptacles that are properly grounded.

Gas, Vacuum, and Electrical Systems Deficiencies

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

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

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

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Smoke Deficiencies

Construct fire resistant interior walls.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

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.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Egress Deficiencies

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

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.

Pharmacy Service Deficiencies

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

Smoke Deficiencies

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

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.

Resident Assessment and Care Planning Deficiencies

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

Quality of Life and Care Deficiencies

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

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.