Autumn Lake Healthcare at Beloit

In the surveyor’s words

From the most serious findings on record at Autumn Lake Healthcare at Beloit, in the surveyor’s own words.

• Immediate jeopardy, widespreadF578Jul 24, 2026

  Based 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. […]

• Immediate jeopardy, widespreadF812Feb 25, 2021

  Based on observation, interview and record review, the facility did not follow proper sanitation and food handling practices in accordance with professional standards for food service safety. This has the potential to affect all 78 residents. The facility failed to consistently check surface temperatures of dishes and utensils in a ware washing machine and failed to take action when temperatures were below minimum wash temperature or outside the range established for the rinse temperature. Additionally on 2/21/21, the external dishwasher temperature gauge was found not to be working. […]

• Actual harm, isolatedF686Nov 25, 2025

  Based 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. […]

• Actual harm, isolatedF689Nov 25, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF804Feb 12, 2026

  Based 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. […]