Federal inspectors found that Autumn Lake Healthcare at Beloit failed to properly assess and treat the resident's facial injury, which was documented in multiple medical scans showing an acute jaw fracture.
The resident, identified as R3 in inspection records, had visible facial bruising that staff attributed to a pre-existing condition. When Nurse Practitioner K first examined him on November 5, she reviewed his admission photo and spoke with facility staff who claimed the bruising was present when he arrived.
But medical records told a different story.
A CT scan performed on September 14 specifically identified the jaw fracture as acute. The resident had no diagnosis of a fractured jaw upon admission to the facility. A follow-up scan on October 11 showed the fracture remained unchanged.
During the inspection interview, the surveyor read the radiology report directly to Nurse Practitioner K, who admitted she did not have that particular exam result in the resident's file. When asked for her clinical impression about whether the fracture was acute or pre-existing, she maintained her belief that it occurred before admission.
"She believes the jaw fracture occurred prior to R3's admission as evidenced by 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," the inspection report states.
The nurse practitioner, who identified herself as an Adult Gerontology Acute Care Nurse Practitioner, estimated that such a fracture would take 8 to 12 weeks to heal in an older adult with multiple health conditions. When the surveyor pointed out that this timeline would mean the fracture should still be visible on the September 14 CT scan if it occurred before admission, she agreed.
The resident also faced additional safety concerns related to his care plan. Inspectors observed that he did not have a urinal at his bedside despite his care plan requiring one. When questioned, staff explained that the resident frequently organized and moved items in his room.
Similarly, a reacher that should have been at his bedside according to his care plan was missing. Staff suggested it might be packed away in a box, citing the resident's behavior of packing his belongings.
The facility's toileting program for the resident also raised questions during the inspection. When asked if the program had ever been adjusted, the Director of Nursing indicated they had added a mid-evening toileting intervention but could not specify an exact time, describing it only as "a general time."
The MDS coordinator and Director of Nursing claimed the current toileting schedule was essentially every two hours, though the actual care plan only listed mid-evening and bedtime care under the toileting section.
When inspectors asked whether a more frequent toileting program might reduce the resident's fall risk, the MDS coordinator defended the current approach, stating that the reduction in fall frequency proved its effectiveness. She noted that the resident's last fall had occurred a little over a month earlier.
The inspection findings highlight a troubling pattern of inadequate medical assessment and care planning. Despite clear radiological evidence of an acute jaw fracture, facility staff maintained their incorrect assessment for months, potentially delaying appropriate treatment and pain management for the resident.
The case raises serious questions about the facility's diagnostic capabilities and willingness to acknowledge medical evidence that contradicts staff assumptions. The resident's fractured jaw remained undiagnosed and untreated while staff insisted the visible injury was someone else's problem.
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.