Autumn Lake Healthcare At Beloit

F 0686 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Care Left ischium- Dakins wound cleanser.Foam dressing to cover wound. Change daily and PRN. Every day and evening shift for wound care.The TAR is blank for day shift on 9/4/25, 9/6/25, 9/14/25, 9/19/25, 9/21/25, 9/28/25, 9/29/25, 10/3/25, 10/5/25, 10/11/25, 10/15/25, 10/16/25, 10/20/25, and 10/21/25.The TAR is blank for evening shift on 9/4/25, 9/14/25, 9/19/25, 10/2/25, 10/16/25, 10/20/25, and 10/21/25. Start 9/7/25. Discontinue 10/22/25. Left heel: Cleanse w/ (with) wound cleanser and pat dry. Apply Hydrogel to wound bed, cover with.foam dress. Change daily.Pressure relieving boots to bilateral feet at all times. every day shift.The TAR is blank on 9/10/25, 9/14/25, 9/17/25, 9/20/25, 9/21/25, 9/28/25, 9/30/25, 10/3/25, 10/5/25, 10/11/25, 10/12/25, 10/16/25, 10/20/25, and 10/21/25. Start 9/7/25. Discontinue 10/22/25. Wound care sacrum - 2 wounds. Dakins wet to moist.Cover with a foam dressing. Change BID (Two Times a Day) and PRN. Every day and evening shift for wound care. The TAR is blank for day shift on 9/14/25, 9/19/25, 9/21/25, 9/28/25, 9/30/25, 10/2/25, 10/3/25, 10/5/25, 10/11/25, 10/15/25, 10/16/25, 10/20/25, and 10/21/25.

The TAR is blank for evening shift on 9/14/25, 9/19/25, 10/2/25, 10/16/25, 10/20/25, and 10/21/25. Start 9/11/25. Discontinue 10/28/25. Dakins (full strength) External Solution 0.5% .Apply to sacral, L (Left) ischial wounds topically two times a day for wound care. The TAR is blank for day shift on 9/14/25, 9/19/25, 9/21/25, 9/28/25, 9/30/25, 10/3/25, 10/5/25, 10/11/25, 10/15/25, 10/16/25, 10/20/25, and 10/21/25. The TAR is blank for evening shift on 9/13/25, 9/14/25, 9/19/25, 10/2/25, 10/16/25, 10/20/25, 10/21/25, 10/23/25, and 10/27/25. Start 10/28/25. Discontinue 11/5/25. Left heel: Wash with wound cleanser. Paint peri wound with betadine. Apply aquacel AG+.cover with secondary foam bordered dressing and change daily & PRN.every day shift. The TAR is blank on 11/1/25 and 11/2/25. Start 10/28/25. Discontinue 11/14/25. Left lateral and right medial foot wounds: pain daily with betadine.every day shift. The TAR is blank on 11/1/25, 11/2/25, 11/9/25, and 11/10/25.Start 10/28/25. Discontinue 11/16/25. Right heel paint peri wound with betadine.

Place aquacel.to wound bed. cover with foam dressing and change daily & PRN every day shift.The TAR is blank on 11/1/25, 11/2/25, 11/9/25, 11/15/25, and 11/16/25.Start 10/28/25. Discontinue 11/14/25. Left hip/tuberosity: cleanse with wound cleanser.place calcium alginate.to the wound bed. Cover with secondary foam dressing. Changed daily & PRN.every day shift for wound care. The TAR is blank on 11/1/25, 11/2/25, 11/9/25, and 11/10/25. Start 10/28/25. Discontinue 11/16/25. Sacral & Left ischial: cleanse wound with wound cleanser.gently pack wounds.cover with foam dressing. Changed daily & PRN.The TAR is blank on 11/1/25, 11/2/25, 11/9/25, and 11/10/25. Start 11/14/25. Bilateral heels: Vashe solution and gauze to each wound bed.cover with dry ABDs (gauze pads used to absorb heavy drainage).change daily and PRN every day shift.The TAR is blank on 11/15/25 and 11/16/25. Start 11/5/25. Discontinue 11/14/25. Left Heel: prior to treatment add vashe ten minute soak to each dressing change.pain peri wound with betadine.cover with secondary dressing.change daily and PRN.every day shift. The TAR is blank on 11/9/25. On 11/24/25 at 12:01 PM, Surveyor interviewed LPN E (Licensed Practical Nurse) regarding completing treatments. LPN E indicated a blank in the TAR means the nurse didn't chart the treatment and if the treatment is not charted then it was not done. On 11/24/25 at 12:07 PM, Surveyor interviewed LPN D regarding completing treatments. LPN D indicated a blank on the TAR means the treatment was not given or done. LPN D indicated the TAR should not have blanks in it.On 11/24/25 at 1:14 PM, Surveyor interviewed WCN C (Wound Care Nurse) regarding completing treatments. WCN C indicated if the TAR is not signed out (blank); the treatment was not done. WCN C indicated treatments should be completed as ordered. On 11/25/25 at 10:47 AM, Surveyor interviewed DON B (Director of Nursing) regarding treatments. DON B indicated if the treatments are not signed out, they are not done. DON B indicated all treatments should be completed.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Lake Healthcare at Beloit

2121 Pioneer Dr Beloit, WI 53511

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

with defining the edge of the bed. Surveyor asked MDS J and DON B if Resident R3's toileting program has ever been adjusted. DON B indicates, they added the mid-evening toileting intervention. Surveyor asked MDS J and DON B if they mean a specific time for the mid-evening intervention or just a generalized block of time.

DON B indicates there is no specific time, just a general time. Surveyor asked MDS J and DON B if the facility ever considered every 2-hour toileting program for Resident R3. DON B indicates she feels like it is pretty much every 2-hour toileting program currently. (Of note: The current toileting program only as mid-evening and HS (bedtime) cares listed under the toileting section). Surveyor asked MDS J and DON B if, in their opinion, a more frequent toileting program may have been effective at reducing Resident R3's fall risk. MDS J indicates she believes that what the facility has in place is effective as evidenced by his reduction in the frequency of his falls with Resident R3's last fall occurring a little over a month ago. Surveyor noted that observations were made of Resident R3 not having a urinal at his bedside, when his care plan indicates he should have one at his bedside. MDS J indicates if it is on his care plan he should have it. However, she does note that Resident R3 is frequently organizing and moving the stuff in his room. Surveyor noted that observations were made of Resident R3 not having a reacher at his bedside, when his care plan indicates he should have one at his bedside. MDS J indicates yes, but reiterates it might be in a box as one of his behaviors is packing his belongings. On 12/2/25 at 12:15 PM, Surveyor interview NP K (Nurse Practitioner). Surveyor asked NP K if she was familiar with Resident R3. NP K indicates, yes. Surveyor asked NP K if she recalled the first time she noted bruising

on Resident R3's face. NP K indicates she first saw Resident R3 on 11/5/25 as she took over for a different provider. When NP K conducted her initial assessment, she also conducted record review and spoke with facility staff who provided Resident R3's admission picture and statements that facial bruising was present on Resident R3's admission. NP K made the statement that the x-ray taken by the hospital stated the jaw fracture was not acute. Surveyor read the radiology report to NP K, which indicates the jaw fracture was acute at the time of the exam. NP K reviewed Resident R3's file and indicated she did not have that particular exam result in the file. Surveyor asked NP K what her clinical impression was regarding whether Resident R3's jaw fracture was acute or sub-acute. NP K indicates she believes the jaw fracture occurred prior to Resident R3's admission as evidenced by the dark purple bruising in Resident 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. Surveyor asked NP K what was her designated specialty. NP K indicates she is an Adult Gerontology Acute Care Nurse Practitioner. Surveyor asked NP K how long she would estimate a fracture like this would take to heal. NP K indicates around 8 to 12 weeks. She indicates in someone young with no comorbidities it may take as little as 6 weeks, however, since Resident R3 is older and has multiple comorbidities, she would expect an 8 to 12-week healing time. Surveyor asked NP K, so then it would be expected to still see the fracture on the CT scan on 9/14/25 if the fracture occurred prior to admission. NP K indicates, yes. (Of note: The CT scan on 9/14/25, indicates the fracture as being acute, Resident R3 did not have a diagnosis of a fractured jaw upon admission, and the fracture was unchanged on 10/11/25)

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