Autumn Lake Healthcare at Beloit

Inspectors wroteBased on interview and record review, the facility failed to ensure staff verified and honored a resident's advance directive of Do Not Resuscitate (DNR) during a medical emergency before initiating cardiopulmonary resuscitation (CPR) and other resuscitative measures for one resident (R1) of six residents reviewed for code status. R1 had a valid Emergency Care Do Not Resuscitate (DNR) order signed by the resident on [DATE] and by the attending physician on [DATE] and entered into resident's record by the facility on R1's readmission on [DATE]. On [DATE], R1 went unresponsive with a faint pulse. Facility staff did not check R1's advance directives before performing Cardiopulmonary Resuscitation (CPR) chest compressions on R1. [...]

Inspectors wroteBased on record review and interviews the facility failed to maintain complete and accurate clinical records, including required weekly skin evaluations and daily skilled nursing documentation reflecting the resident's clinical status for two of six residents (R2 and R3) reviewed for medical records. R2 and R3 had incomplete clinical record that did not accurately reflect the resident's condition and risked effective clinical decision-making or a delay in recognition of worsening condition that could lead to hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that each resident receives food that is palatable and at a safe and appetizing temperature affecting 4 out of 5 units with the potential to affect all 80 residents (R) residing in the facility. Six residents voiced concerns over hot foods being served cold. (R29, R32, R9, R25, R2, and R76) 2 of 2 test trays were observed to be served at non-desirable temperatures. Evidenced by: The facility policy Food Preparation and Service Policy revised 8/25, states in part: . Thermal cooking temperatures for ground meat is 155 degrees. Fresh, frozen, or canned vegetables are cooked to holding temperature of 135 degrees. Previously cooked food is reheated to an internal temperature of 165 degrees for at least 15 seconds. Example 1 On 02/10/2026 at 9:16 AM Surveyor interviewed R76 during the initial screening. [...]

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 80 residents who reside in the facility. Surveyor observed food in circulation that was opened and undated or expired. Facility failed to have a system for manually monitoring the internal temperature of the dishwasher. This is evidenced by: Example 1 (Food dating)FDA Food Code, 2017, include: . Refrigeration Requirements Refrigeration times and temperatures to inhibit C. botulinum and L. monocytogenes must be based on laboratory inoculation study data or follow one of the ROP methods in Section 3-502.12 which specifies the time and temperature combinations. The . [...]

Inspectors wroteBased on interview and record review the facility did not ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 Residents (R) reviewed for Pain (R1) R1 voiced concerns regarding his pain regime not being effective. R1's MAR (Medication Administration Record) indicated that R1 has pain ratings of 0 out of 10 while R1 indicates he is never lower than a 4 out of 10. R1's Comprehensive Care Plan does not contain goals or interventions related to pain management. Evidenced by:Facility policy, titled Pain Management, reviewed 5/25/25, includes, in part: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that sufficient nursing staff was provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident (R) for 2 of 6 residents reviewed (R3 and R4). The facility assessment indicates a staffing plan that requires 4 licensed nurses on the Day shift, 2-4 licensed nurses on the Evening shift, and 2 licensed nurses on the Night shift. The plan also requires a direct care staff, indicated to be a total of licensed or certified staff, ratio of 1:16-18 on Day shift, 1:16-18 on Evening shift, and 1:20 ratio on Night shift. From 12/23/25 - 1/4/25, the facility had multiple shifts below the facility assessment's required staffing ratio. R3 voiced concerns about being left on the commode too long and that wait times are too long when using the call light. [...]

Inspectors wroteBased on interview, and record review, the facility did not 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 (R3) of 6 residents reviewed for medication errors. R3 did not receive her ordered Potassium Gluconate (Mineral supplement) on 12/10/25, 12/11/25, 12/12/25, 12/13/25, 12/14/25, and 12/15/25. R3 also did not receive her ordered Calcium and Vitamin D3 (supplement) on 12/11/25, 12/12/25, 12/14/25,12/15/25, 12/16/25, 12/17/25, 12/18/25, 12/19/25, 12/20/25, and 12/22/25. Both supplements were not given as ordered due to the medication being unavailable in the facility. This is evidenced by: The facility policy entitled, Medication Error Identification and Prevention, dated 03/25, states, in part: . [...]

Inspectors wroteBased on interview and record review, the facility did not ensure staff postings were accurate which has the potential to affect 80 out of 80 residents residing at the facility. Review of staffing schedules and required staff postings revealed discrepancies between the documents. The total number of staff hours worked was not listed on the documents for licensed and non-licensed staff directly responsible for resident care each shift. This is evidenced by: Surveyor reviewed the schedules and staff postings from 12/24/25 through 1/4/26 and noted the following inaccuracies: None of the postings contained the total number of hours worked, only the actual hours worked for nurses and CNAs. Under the section titled, Staffing Total, the number of staff at each license or certification level is listed but not the total hours worked by that license or certification level. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure each resident receives care, consistent with professional standards of practice (SOP), to prevent pressure injuries (PI) and each resident with PIs receives necessary treatment and services, consistent with professional SOP, to promote healing, prevent infection, and prevent new injuries from developing in 2 of 3 sampled residents (R1 and R6). (R6 is being cited at actual harm/isolated). R6 was identified to be at risk for PI development and re-developed a stage IV PI. Observations were made of PI interventions not being used as intended. Wound assessments were not completed weekly, and treatments were not completed as ordered. R6 re-developed a stage IV PI which deteriorated. R1's PI was not staged accurately. R1 did not have PI treatments completed as ordered. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a resident's environment remained free of accidents and hazards for 1 of 3 residents (R3) reviewed for falls. R3 had a comprehensive care plan for being a high fall risk upon his admission on [DATE]. R3 experienced four falls at the facility since his admission. On 9/3/25, R3 experienced an unwitnessed fall without major injury. On 9/14/25, R3 experienced an unwitnessed fall with a subsequent left mandibular (lower bone of jaw) fracture. On 10/7/25, R3 experienced an unwitnessed fall without major injury. On 10/11/25, R3 experienced an unwitnessed fall with a subsequent left tenth rib fracture. R3's comprehensive care plan included interventions of having a urinal at bedside, a reacher and a call light within reach. Observations were made of R3 not having these interventions at bedside. [...]

Inspectors wroteBased on interview, record review, and review of the admission Agreement, the facility failed to ensure that 3 of 5 sampled residents (R1, R2, and R3) were provided with choices regarding baths/showers. R1, R2, and R3 were not offered choices regarding the frequency of showers, and each received one shower per week according to the facility shower schedule. R1, R2, and R3 did not receive an adequate number of showers to meet their needs.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to ensure 1 of 5 sampled residents (R2) with an urostomy had their urostomy bag stored in a sanitary manner to prevent cross contamination and the potential spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 77 residents residing at the facility. Surveyor observed walk-in freezer to have water dripping from ceiling, chunks of ice on a box of food, chunks of ice around the freezer door, and ice chips on the floor. Surveyor observed the freezer thermometer to read 25 degrees Fahrenheit. Surveyor observed an open blue bag of broccoli, out of its original packaging, with no label or date. The bag had ice chunks in it. Surveyor observed a bag of biscuits with no date. Surveyor observed a package of hot dogs, out of its original packaging, with no label or date. Surveyor observed microwave to have a black spot on the top of the microwave. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure it maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections. The facility does not have a water management plan that identifies all areas where Legionella and other opportunistic waterborne pathogens can grow and spread. This had the potential to affect all 77 residents (R) in the facility. The facility's water management plan did not identify/assess through text and flow diagrams areas where Legionella and other opportunistic waterborne pathogens can grow and spread. CNA C (Certified Nursing Assistant) did not follow appropriate infection control procedures to prevent the spread of infection. This is evidenced by: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure a resident who requires two-person assist for transfers, transfer safely to prevent accidents for 3 out of 23 residents reviewed for accidents. (R62, R3, R66) R62 indicated there are times she is transferred by one staff and R62's care plan indicates she is a two-person transfer assist. R3 indicated there are times she is transferred by one staff and R3's care plan indicates she is a two-person transfer assist. R66 uses a full body lift and facility staff transfer with one staff not two. Evidenced by: The facility policy, Safe Resident Handling/Transfer Policy, dated 2/23, states, in part: Policy: [...]

Inspectors wroteBased on interview, and record review, the facility did not ensure a resident who requires BiPAP respiratory support was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 1 residents (R62) reviewed with BiPAP. R62 indicated to Surveyor it took over an hour and a half on 6/23/23 for staff to assist R62 with BI-PAP machine. R62 indicated she eventually had to call the facility to receive assistance. Evidenced by: The facility policy, ADL Care Sheet Policy, dated 4/23, states, in part: [...]