Autumn Lake Healthcare at Beloit

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. Example 1 On 02/10/2026 at 9:16 AM Surveyor interviewed R76 during the initial screening. R76 resides on Skyline hallway. R76 indicated that his food was sometimes hot, but mostly not because they do the dining room first then the rooms. Example 2 On 02/10/2026 at 9:27 AM Surveyor interviewed R2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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 . package must be marked with a use-by date within either the manufacturer's labeled use-by date or as determined by the laboratory data, whichever comes first . Labeling - Use-by date The shelf life of ROP foods is based on storage temperature for a certain time and other intrinsic factors of the food (pH, aw, cured with salt…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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: (The facility) ensures 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 resident's goals and preferences.In order to help a resident maintain or attain his/her highest…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. R4 voiced concerns about staff not having enough help, that all the time there is only 1 CNA for 24-25 residents, she has to wait a long time.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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: . When a medication error occurs, the Charge Nurse must be notified immediately. A nursing assessment of the resident must take place immediately to ensure that any…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: During an interview on 12/21/23 at 7:23 PM, NHA A (Nursing Home Administrator) stated the facility did not have a policy for resident choice/choices; however, there was some information in the admission Agreement. The facility's undated admission Agreement states, Each resident is treated with consideration, respect, and full recognition of dignity and individuality .Each resident is encouraged and assisted, throughout the period of stay, to exercise rights .and to this end may voice grievances and recommend changes in policies and services to facility staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Review of the Pouch Changes-Colostomy, Urostomy, and Ileostomy Policy dated 10/2023 revealed, Urostomy - a stoma for the urinary system used in cases where long-tern drainage of urine through the bladder and urethra is not possible . items soiled with urine or fecal matter (i.e urostomy bags or tubing) must be handled so as to prevent contamination of the environment with urine or feces. Such items must be placed in closed containers . R2 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm (cancerous tumor) of the bladder and urinary tract infection (UTI). Review of the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/13/23 revealed R2 had a BIMS of 14, which indicated R2 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Surveyor observed food splatters and crumbs in microwave. Evidenced by: The facility policy, entitled Food Receiving and Storage, states, in part: . Policy Statement- Foods shall be received and stored in a manner that complies with safe…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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: The facility policy titled, Water Management Policy, with a Reviewed/Revised date of 4/2023, indicates, in part: Policy: It is the policy of [NAME] Lake Healthcare at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines .Compliance Guidelines: .4. Mechanical lifts may…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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: Policy .utilizes ADL care sheets to communicate resident care needs and preferences with nursing staff .The ADL care sheet is based on a collection of data, including but not limited to the resident's comprehensive assessment and is consistent with the resident's needs and preferences Procedure .ADL care sheets include pertinent information for staff to utilize in an easily accessed form to deliver resident care needs. ADL…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.