Autumn Lake Healthcare at Greenfield

In the surveyor’s words

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

• Immediate jeopardy, patternF686Jun 24, 2026

  Based on observation, interview and record review, the facility failed to ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 7 (R66, R109, R34, R10, R33, R5 and R8) of 13 residents reviewed for pressure injuries from a sample of 19. *R66 has a history of a healed stage 4 pressure injury to the sacrum and is at high risk for pressure injuries. R66's sacral pressure injury reopened on 1/17/25 and again on 6/10/25. On 11/21/25, R66's sacral pressure injury showed signs of infection and a wound culture was ordered. Results on 11/24/25 documented a staph infection. […]

• Immediate jeopardy, isolatedF684Jun 24, 2026

  Based on interview and record review, the facility failed to ensure 4 (R21, R66, R109, and R7) of 19 sampled residents received treatment and care based upon a comprehensive assessment and a comprehensive person centered plan of care and in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act.) *R21 returned from an appointment outside of the facility on 10/27/25 with a large hematoma on the front of R21's left shin. R21's leg wound opened and needed to be debrided on 11/19/25. On 11/26/25, R21's left leg wound became infected. Facility staff did not follow Wound Nurse Practitioner (NP)-F's treatment orders. […]

• Immediate jeopardy, isolatedF600Dec 13, 2025

  Based on record review, interviews, and policy review, the facility failed to ensure residents were free from sexual abuse for 1 resident (R) of 3 residents reviewed for abuse (R2), R1 had a previous documented incident of trying to kiss another resident and there was a reported incident of R1 attempting to fondle the breasts of R2, a cognitively impaired resident. The facility failed to implement effective preventive measures after these incidents. R1 was later found by staff with his hand down R2's pants. Following this incident, not all caregivers were aware of the need to monitor the whereabouts of R1 or to keep R1 and R2 separated.The facility's failure to keep R2 free from sexual abuse created a finding of immediate jeopardy that began on 11/20/25. […]

• Immediate jeopardy, isolatedF684May 25, 2021

  Based on interview and record review the facility did not ensure that 2 (R1 & R6) of 9 Residents reviewed received treatment and care in accordance with professional standards of practice. On [DATE] R1 experienced a change of condition as she was not yelling out per her norm, CNA (certified nursing assistant) -N elevated the head of the bed and left R1's breakfast tray in front of her as R1 could feed herself after set up. R1 did not eat any of her breakfast and R1 did not respond when CNA-N attempted to feed her breakfast. R1 did not respond when CNA-N provided personal cares and R1 did not assist with turning herself as she normally did during cares. […]

• Actual harm, isolatedF689Jun 24, 2026

  Based on observation, interview and record review, the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for 4 (R11, R33, R7 and R108) of 7 sampled residents reviewed for accidents. *On 3/27/26, at 6:15 AM, R11 sustained an unwitnessed fall that resulted in a right hip fracture requiring surgery. R11 was found lying on their fall mat next to their bed by facility staff. R11 was assessed as having difficulty with performing Range of Motion (ROM) with their right leg and increased pain. Facility staff used a mechanical lift to get R11 back into bed even though R11 had changes with their right leg ROM and increased pain. […]