Federal inspectors found that Autumn Lake Healthcare at Beloit failed to properly assess and treat the resident's jaw fracture, which was documented as acute in multiple medical examinations but dismissed by facility staff as a pre-existing condition.
The resident, identified as R3 in inspection documents, had visible facial bruising that staff attributed to injuries sustained before his admission. However, CT scans from September 14 and October 11 both identified the jaw fracture as acute, contradicting the facility's claims.
Nurse Practitioner K, who took over the resident's care on November 5, told inspectors she believed the jaw fracture occurred prior to admission. She cited the "dark purple bruising in R3's admission photo, the lack of an x-ray of his facial bones during his hospital stay prior to admission, staff reports, and record review" as evidence.
But when inspectors read the actual radiology report to the nurse practitioner, it clearly stated the jaw fracture was acute at the time of the exam. The nurse practitioner acknowledged she did not have that particular exam result in the resident's file.
The resident never received a diagnosis of fractured jaw upon admission. Medical records show the fracture remained unchanged between the September and October scans, indicating it had not healed during that time period.
When asked about healing time, the nurse practitioner estimated 8 to 12 weeks for someone of the resident's age with multiple health conditions. She acknowledged that if the fracture had occurred before admission, it would still be expected to show on the September 14 CT scan.
The inspection also revealed problems with the resident's fall prevention program. R3 had a history of falls, yet his toileting schedule included only "mid-evening" and bedtime care, with no specific times designated for the interventions.
Director of Nursing B told inspectors there was "no specific time, just a general time" for the mid-evening toileting. When asked if the facility had considered a more frequent every-two-hour toileting program, she claimed they essentially already had one in place, despite the care plan showing only two daily interventions.
MDS Coordinator J defended the current approach, telling inspectors she believed their program was effective because the resident's falls had decreased, with his last fall occurring "a little over a month ago."
Inspectors observed that essential items listed in the resident's care plan were missing from his bedside. He lacked both a urinal and a reacher, despite his care plan requiring these items to be available.
Staff explained the missing equipment by noting the resident's tendency to organize and move items around his room. The MDS coordinator said the reacher "might be in a box as one of his behaviors is packing his belongings."
The facility's failure to properly diagnose the jaw fracture meant the resident did not receive appropriate treatment for weeks. The acute nature of the fracture, confirmed by multiple medical examinations, indicated it required immediate medical attention that was delayed due to staff assumptions about pre-existing injuries.
Federal inspectors classified the violation as causing actual harm to few residents. The case illustrates how nursing home staff's misinterpretation of medical evidence can lead to delayed treatment and prolonged suffering for vulnerable residents who depend on facility staff to advocate for their medical needs.
The resident's broken jaw remained untreated while staff maintained their incorrect assessment, despite clear medical evidence documenting the injury as acute and requiring immediate intervention.
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.