Autumn Lake Beloit: Resident Harm, No Fix Plan - WI
The wounds required daily treatment, sometimes twice daily. Nurses were supposed to cleanse each site, apply medicated solutions, pack the deeper wounds, and cover them with foam dressings. The treatment administration records, where staff sign after completing each procedure, were blank across all of it, day shift and evening shift alike.
The left ischium wound alone had 14 blank day-shift entries and 7 blank evening-shift entries over a six-week span. The sacral wounds, two of them, had 13 blank day-shift entries and 6 blank evening-shift entries. The left heel accumulated 14 missed day-shift treatments before that order was discontinued and replaced with a new one, which then had its own blanks within days of starting.
Nobody disputed what the blanks meant. Licensed Practical Nurse E told the surveyor that 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: not given, not done, and the TAR should never have blanks. The wound care nurse said treatments should be completed as ordered. The director of nursing confirmed that unsigned entries mean the treatments weren't completed.
The inspection, a complaint survey, was conducted November 25, 2025. CMS rated the violation as causing actual harm to the resident.
The facility sits on Pioneer Drive in Beloit. The resident's wounds were still being treated, under new orders, in the days before inspectors arrived.
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.
The wounds required daily treatment, sometimes 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.