Inspection Reports for Autumn Lake Healthcare at Beloit

The facility was found deficient in providing appropriate pressure ulcer care and preventing new ulcers, with failures in timely wound assessments and treatment administration. Additionally, the facility did not ensure a resident's environment was free from accident hazards and did not provide adequate supervision to prevent falls, resulting in multiple falls and injuries for one resident.

The complaint investigation was triggered by grievances and family member reports that residents were not receiving adequate showers and that R2's urostomy bag was improperly stored, posing infection risks. The complaint was substantiated based on interviews, record reviews, and observations.

The facility failed to ensure that 3 of 5 sampled residents (R1, R2, and R3) were provided choices regarding baths/showers and did not provide an adequate number of showers to meet their needs. Additionally, the facility failed to ensure that resident R2's urostomy bag was stored in a sanitary manner to prevent cross contamination and potential infection.

The complaint investigation found that residents requiring two-person assist for transfers were sometimes transferred by only one staff member due to staffing shortages. The complaint was substantiated with evidence from resident interviews, care plans, and staff statements.

The facility failed to ensure that residents who require two-person assistance for transfers were consistently transferred safely, with staff sometimes using only one person for transfers despite care plans indicating two-person assist. This was evidenced by interviews and record reviews of three residents and staff statements acknowledging staffing shortages.

The visit was complaint-related, triggered by allegations of unsafe resident transfers, delayed respiratory care, food safety issues, and infection control lapses. Substantiation status is not explicitly stated.

The facility failed to ensure safe two-person transfers for residents requiring such assistance, resulting in potential accident hazards. There was a delay in providing BiPAP respiratory support to a resident. Food storage and preparation practices did not meet professional standards, including improper labeling and freezer conditions. Infection prevention and control practices were inadequate, including improper handling of ointments by staff and lack of a comprehensive water management plan to control Legionella risks.

The facility was found deficient in multiple areas including failure to create discharge care plans reflecting residents' goals, lack of arrangement with dialysis providers, inadequate full-time Director of Nursing coverage, food served at improper temperatures, excessive time between evening meal and breakfast without snacks, unsanitary food preparation and storage conditions, employment of unlicensed nursing staff, and failure to maintain an effective infection prevention and control program.