Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Beloit during CMS and state inspections, most recent first.
Food Served at Unappetizing Temperatures: Multiple residents reported that meals were often cold or only lukewarm in both rooms and dining areas, with some needing food microwaved before eating. Surveyors observed two trays with meat and side items served at lukewarm temperatures and described as unpalatable. Staff acknowledged complaints about cold food and noted they did not have a thermometer on the floor to verify temperatures.
Food storage and warewashing practices were deficient when a Dietary Manager found expired buns, unlabeled Italian dressing, and multiple expired Mighty Shakes in a kitchenette. Surveyor also observed the dishwasher being used without a consistent manual temperature monitoring system; the gauge did not move during cycles, test strips were only used when a problem was suspected, and the strips observed had no expiration date.
A resident with burn injuries and polyneuropathy reported persistent leg pain, usually around 6/10 and never below 4/10, but the pain risk assessment was largely incomplete and the care plan lacked pain goals and interventions. The MAR/TAR mostly recorded pain as 0 despite the resident’s reports, PRN hydrocodone-acetaminophen was sometimes documented as effective, once as ineffective, and once as unknown, and nursing notes did not show what staff did when the medication was ineffective. Staff, including the DON and NHA, acknowledged the assessment and care plan deficiencies.
The facility failed to maintain sufficient licensed nurse and direct care staffing in accordance with its own facility assessment, resulting in repeated shifts where only one nurse covered approximately 80 residents and CNA-to-resident ratios exceeded stated targets. Over multiple days and shifts, the number of RNs/LPNs and CNAs fell below the planned 4 nurses on days, 2–4 on evenings, 2 on nights, and direct care ratios of 1:16–18 on days/evenings and 1:20 on nights. A resident with joint replacement aftercare, nerve injury, morbid obesity, and CHF reported being left on the commode too long and waiting up to an hour for call light responses, while another resident with acute on chronic CHF, morbid obesity, and mobility issues reported that there is often only one CNA for 24–25 residents and that long waits occur "all the time." Staff interviews confirmed difficulty completing tasks due to staffing levels, reliance on pool staff and staff staying late or coming in early, and acknowledgment by the scheduler and DON that staffing should follow the facility assessment, even as the DON noted that night shift sometimes has only one nurse on duty.
A resident with multiple chronic conditions, including CHF, vascular dementia, and prior joint replacements, did not receive ordered Potassium Gluconate and Calcium/Vitamin D3 supplements on multiple occasions because the medications were unavailable. An LPN marked the missed doses on the MAR with an "other" code but did not complete corresponding nurse notes. Facility policy defines such omissions as medication errors and requires immediate assessment, documentation, and physician and family notification. The DON reported that over-the-counter medications should be restocked through the contracted pharmacy, that a coded MAR entry should have associated documentation, and that management should be informed, but the DON was not made aware of these omissions.
The facility did not ensure that daily nurse staffing postings were accurate and complete for all residents. Review of staffing schedules and posted information over multiple days showed discrepancies, with postings lacking the total number of hours worked by licensed and non-licensed staff directly responsible for resident care on each shift. The postings only listed actual hours worked for nurses and CNAs and, under "Staffing Total," showed the number of staff by license or certification level without including total hours worked for each category. The DON acknowledged that the staff postings are expected to match the staff schedule.
Two residents did not receive care consistent with professional standards for pressure injury (PI) prevention and treatment, including missed or delayed wound assessments, incomplete or undocumented wound care treatments, and improper use of pressure-relieving devices. Staff interviews and record reviews confirmed that required interventions were not consistently implemented or documented.
A resident with multiple comorbidities and cognitive impairment experienced repeated unwitnessed falls, resulting in serious injuries, due to the facility's failure to ensure required fall prevention interventions—such as a bedside urinal, reacher, and accessible call light—were consistently in place as outlined in the care plan. Staff interviews and observations confirmed these interventions were missing, despite the resident's high fall risk and the facility's own policies.
Food Served at Unappetizing Temperatures
Penalty
Summary
The facility did not ensure that residents received food that was palatable and at a safe and appetizing temperature. Six residents voiced concerns that hot foods were being served cold or only lukewarm, including reports that meals were generally cold in rooms and dining areas, that food needed to be microwaved before being eaten, and that dining service often occurred first in the dining room and later in resident rooms, leaving trays cold by the time they were delivered. Residents on multiple hallways reported that meals were not hot, and one resident stated the facility did not have warmers under the plates or heated carts. Surveyors observed two test trays served at non-desirable temperatures. On the Genesis Memory Care Unit, the last tray served in the dining room contained pureed meat at 120 degrees, pureed sweet potatoes at 124 degrees, and pureed peas at 127 degrees, and the items were described as lukewarm and unpalatable. On Horizon Hallway, the last room tray had meatloaf at 125.2 degrees and sweet potatoes and peas at 124.0 degrees, also described as lukewarm and unpalatable. Staff interviews reflected awareness of the issue, with an RN stating there were many complaints about cold food on the hallway and a CNA stating she would heat food if it was cold but did not know the temperature because she did not have a thermometer on the floor. The Dietary Manager stated she would expect hot food to be hot and acknowledged the resident concerns and test tray temperatures.
Food Storage and Dishwasher Temperature Monitoring Deficiencies
Penalty
Summary
The facility did not maintain a safe and sanitary environment for food preparation, storage, and distribution. During an initial kitchen walk-through with the Dietary Manager, surveyor observed a package of buns in the refrigerator that had expired on 2/8/26. The Dietary Manager stated the buns should be thrown away because they were expired and discarded them. Surveyor also observed a container of Italian dressing in the refrigerator with no label or date; the Dietary Manager stated it should have a label, open date, and expiration date and discarded it. On 2/12/26, surveyor observed one kitchenette with 23 Mighty Shakes that were past the 14-day thaw date. The shakes had use-by dates of 1/20, 1/26, and 2/10, and the manufacturer’s carton stated the shakes were good for 14 days once refrigerated. When asked how long the shakes were good after being pulled from the freezer, the Dietary Manager stated they were good for 2 weeks. When asked if the shakes were expired, the Dietary Manager stated yes and discarded them. The Dietary Manager stated that everyone on the unit was responsible for checking expiration, but only the nurse gives out the supplement. Surveyor also observed the facility did not have a system for manually monitoring the internal temperature of the dishwasher. During dishwashing, the outside thermometer read 151 degrees while the Dietary Aide ran a tray through the machine, and the Dietary Manager directed additional empty trays to be run to see if the water would come up to temperature. The needle on the temperature gauge did not move during later cycles, and the Dietary Manager stated she would use a test strip to test the water. She stated she only used the 160-degree test strips when they thought there was a problem with temperature. The test strips observed had no expiration date, and the Dietary Manager and Nursing Home Administrator both stated that the facility should have a system in place for manually monitoring the internal temperature of the dishwasher.
Incomplete pain assessment and care planning for resident with chronic burn pain
Penalty
Summary
The facility did not ensure safe, appropriate pain management for a resident with significant burn injuries and polyneuropathy. The resident was admitted with diagnoses including polyneuropathy, burns of the lower legs, burns involving 10-19% of body surface area, and complications of skin graft/allograft/autograft. During interview, the resident stated his leg wounds from a prior apartment fire were very painful, caused anxiety, and that his pain was typically around 6 out of 10 and never lower than 4 out of 10. He also stated he wanted staff to help keep his pain at or below a level 4. The resident’s pain risk assessment was incomplete, with multiple sections left blank, including diagnosis related to pain risk, pain site examination, factors that worsen or relieve pain, current pain medication regimen, pain goal, and plan of care. The resident’s comprehensive care plan included only a general statement to treat pain as ordered prior to treatment or turning, and did not contain specific pain goals or interventions, including non-pharmacological interventions. Staff interviews confirmed the care plan lacked pain goals and interventions, and the CNA stated she relies on the care plan to know what she can do when the resident is in pain. The MAR/TAR showed pain assessments documented every shift, but most entries recorded pain as zero despite the resident reporting ongoing pain levels ranging from 4 to 9. The resident had PRN hydrocodone-acetaminophen ordered for pain, with some entries documenting the medication as effective, one entry documenting it as ineffective, and one entry documenting effectiveness as unknown. Nursing notes did not document what staff did when the medication was ineffective. The DON and NHA acknowledged that the pain assessment should have been fully completed, staff should document what they do when medication is ineffective, and the care plan should include goals and interventions related to pain management.
Failure to Maintain Sufficient Nursing and Direct Care Staffing to Meet Resident Needs
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs in accordance with its own Facility Assessment and staffing policy. The Facility Assessment dated July 2025 specifies a staffing plan of 4 licensed nurses on the day shift, 2–4 licensed nurses on the evening shift, and 2 licensed nurses on the night shift, with direct care staff ratios of 1:16–18 on day and evening shifts and 1:20 on night shift. Review of staffing schedules from late December through early January showed multiple shifts where the number of licensed nurses and direct care staff fell below these stated ratios. On several dates, there was only 1 licensed nurse on night shift for a census of approximately 80–84 residents, resulting in nurse-to-resident ratios as high as 1:84, and direct care staff ratios as high as 1:28 during portions of the night. From 12/23/25 through 1/6/26, the surveyor identified repeated instances of inadequate staffing compared to the facility’s own assessment. Examples include: on 12/24/25, the day shift had 3 licensed nurses with a 1:28 ratio instead of 4, and the night shift had 1 licensed nurse with a 1:84 ratio and only 3 direct care staff with a 1:28 ratio from 10:00 PM to 5:00 AM. On 12/25/25, the day shift again had 3 licensed nurses (1:28), the evening shift had 2 licensed nurses (1:42), and the night shift had 1 licensed nurse (1:84). Similar shortfalls occurred on 12/26/25, 12/29/25, 12/30/25, 12/31/25, 1/2/26, 1/3/26, and 1/4/26, with periods where only 1 licensed nurse covered the entire building and direct care staff numbers did not meet the 1:16–18 or 1:20 ratios. On some days, the facility could not provide the required staffing postings for census confirmation. Two cognitively intact residents reported care concerns consistent with these staffing shortages. One resident, with diagnoses including aftercare following joint replacement, radial nerve injury, vascular dementia, morbid obesity, adult failure to thrive, muscle weakness, and chronic congestive heart failure, stated that staff leave her on the commode too long and that she must sometimes wait an hour for her call light to be answered to use the bathroom, describing the waiting as getting “out of line.” Another resident, with acute on chronic congestive heart failure, disorientation, morbid obesity, muscle weakness, difficulty in walking, and adult failure to thrive, reported that there is often only one CNA for a hall of 24–25 residents, that this happens “all the time,” and that she has to wait a long time. Staff interviews further reflected staffing strain: one CNA stated it is hard to complete all tasks on her shift and acknowledged general short staffing, while the scheduler/CNA described relying on full-time/part-time set schedules, pool staff, and staff coming in early or staying late to fill gaps, and confirmed that staffing should follow the facility assessment. The DON stated that a 1:40 nurse-to-resident ratio for PM and NOC shifts was considered safe due to ancillary staff, acknowledged that night shift sometimes has only one nurse on duty, and confirmed that staffing is an ongoing concern discussed at QAPI meetings, even though no ancillary staff were actually scheduled on the reviewed schedules.
Failure to Provide Ordered Potassium and Calcium/Vitamin D Supplements Due to Medication Unavailability and Lack of Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of ordered medications for one resident. The resident had multiple diagnoses, including aftercare following joint replacement surgery, radial nerve injury, vascular dementia, morbid obesity, adult failure to thrive, need for assistance with personal care, presence of right artificial hip and left artificial shoulder joints, muscle weakness, and chronic congestive heart failure. Review of the Medication Administration Record (MAR) showed that ordered Potassium Gluconate 550 mg and Calcium + Vitamin D3 600-5 mg–mcg supplements were not administered on multiple documented dates. These MAR entries were marked with a “9” by an LPN, indicating “Other/See Nurse Notes,” but there were no corresponding nurse’s notes explaining why the medications were not given. During interview, the LPN stated that both supplements were unavailable in the facility on the dates they were not administered and reported that she had informed management and ordered additional supplies from the pharmacy, as the medications were over-the-counter. The facility’s policy on Medication Error Identification and Prevention defines omission errors as failure to administer an ordered dose and requires immediate nursing assessment, physician and family notification, documentation in the electronic medical record, and implementation of steps to prevent recurrence. The DON explained that over-the-counter medications are restocked by contacting the contracted pharmacy and that staff are expected to complete medication error paperwork, provide immediate education, notify the physician and family, and document associated notes when a “9” is used on the MAR. The DON stated that a “9” should have associated documentation and that management should be informed, but also reported not being made aware of these specific medication omissions for the resident.
Inaccurate and Incomplete Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that daily nurse staffing postings were accurate and complete, affecting all 80 residents. Surveyor review of staffing schedules and required staff postings for the period from 12/24/25 through 1/4/26 showed discrepancies between the schedules and the posted information. None of the postings contained the total number of hours worked by licensed and non-licensed staff directly responsible for resident care on each shift; instead, they only listed the actual hours worked for nurses and CNAs. In the section labeled "Staffing Total," the postings listed the number of staff at each license or certification level but did not include the total hours worked by each category. During an interview on 1/6/26 at 4:10 PM, the DON confirmed that the staff postings should match the staff schedule.
Failure to Prevent and Treat Pressure Injuries per Professional Standards
Penalty
Summary
The facility failed to ensure that residents received care consistent with professional standards of practice to prevent and treat pressure injuries (PIs) in two of three sampled residents. For one resident with a history of a stage IV pressure injury, the facility did not consistently implement prescribed interventions, such as the use of a pressure redistribution cushion in the wheelchair, which was observed to be missing or improperly placed. Wound assessments were not completed weekly as required, and there were delays in initiating and documenting wound treatments. Treatment Administration Records (TARs) contained multiple blanks, indicating that ordered treatments were not completed or not documented as done. Interviews with staff confirmed that if the TAR was blank, the treatment was not performed. Another resident, who was at high risk for pressure injuries due to paraplegia, had a pressure injury that was not accurately staged according to professional guidelines. The wound was documented as a stage II pressure injury despite the presence of slough, which is inconsistent with the definition of stage II. This resident also had multiple instances where wound care treatments were not completed as ordered, as evidenced by numerous blanks in the TAR across various shifts and dates. Staff interviews corroborated that these blanks meant treatments were not provided. The facility's own policy required comprehensive assessment and documentation of skin integrity upon admission and for new or worsening wounds, as well as routine wound rounds and adherence to the most recent NPIAP guidelines. Despite these policies, both residents experienced lapses in care, including missed or delayed wound assessments, incomplete or undocumented treatments, and failure to ensure the use of prescribed pressure-relieving devices. These deficiencies were confirmed through observation, record review, and staff interviews.
Failure to Maintain Accident-Free Environment and Implement Fall Prevention Interventions
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident's environment was free from accident hazards and did not provide adequate supervision to prevent accidents for one resident identified as high risk for falls. The resident, who had multiple diagnoses including muscle wasting, vascular dementia, hemiplegia, and moderate to severe cognitive impairment, experienced four unwitnessed falls during their stay. These falls resulted in significant injuries, including a mandibular fracture and a rib fracture. The resident's care plan included specific interventions such as keeping a urinal and reacher at bedside, ensuring the call light was within reach, and providing assistance with activities of daily living and toileting. Despite these care-planned interventions, observations and interviews revealed that the urinal and reacher were not present at the resident's bedside as required. The call light was also observed on the floor and not always within reach. Staff interviews confirmed that these interventions should have been in place according to the care plan, but they were not consistently implemented. The facility's own policies, including the Falling Star Program for high fall risk residents, were not fully adhered to, as evidenced by the lack of required fall prevention equipment in the resident's room. Documentation showed that the resident's falls were frequently related to attempts to self-transfer, particularly to use the bathroom, and that interventions such as a bedside urinal were specifically intended to address this risk. However, the absence of these interventions contributed to repeated falls and injuries. The facility's monitoring and communication systems did not ensure that all staff were aware of and consistently implemented the required fall prevention measures for this high-risk resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Beloit
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beloit Health And Rehabilitation Center | 1.1 mi | ★★★★★ | 19 | 0 |
| Fair Oaks Rehab & Healthcare | 3.8 mi | ★★★★★ | 26 | 1 |
| Alden Meadow Park Hcc | 8 mi | ★★★★★ | 11 | 0 |
| Cedar Crest Health Center | 8.8 mi | ★★★★★ | 4 | 0 |
| Oak Park Place Of Janesville | 9.7 mi | ★★★★★ | 1 | 0 |
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