Autumn Lake Beloit: Pressure Ulcer Harm Found - WI
Inspectors reviewing treatment administration records found blank after blank: day shifts, evening shifts, wounds that were supposed to be treated twice daily. The left ischium wound alone went undressed on at least 21 shifts between September 4 and October 21. The sacral wounds, which required twice-daily changes, had gaps on 19 documented shifts. The left heel, which required pressure-relieving boots at all times alongside daily wound care, was skipped 14 times in the same period.
The gaps continued into November. New wound orders covering both heels, the left lateral foot, the right medial foot, the right heel, the left hip, and the sacrum all showed blank treatment records on November 1 and 2, then again on November 9 and 10.
When the surveyor asked what a blank meant, the answers were unanimous. LPN E said a blank means the nurse didn't chart the treatment, and if it wasn't charted, it wasn't done. LPN D said the same: the treatment was not given, and the records should never have blanks. The facility's wound care nurse said treatments should be completed as ordered. The Director of Nursing said if treatments are not signed out, they are not done.
All of them said what the records already showed.
CMS rated the violation as causing actual harm to residents. The inspection was completed November 25, 2025.
The resident's wounds required Dakins solution, hydrogel, calcium alginate, betadine, Vashe soaks, and foam dressings — a regimen that changed and expanded as the wounds changed, and that depended entirely on staff showing up, shift after shift, to do the work. On the days the records go blank, that work did not happen.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Autumn Lake Healthcare At Beloit from 2025-11-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
AUTUMN LAKE HEALTHCARE AT BELOIT in BELOIT, WI was cited for violations during a health inspection on November 25, 2025.
Inspectors reviewing treatment administration records found blank after blank: day shifts, evening shifts, wounds that were supposed to be treated twice daily.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.