Beloit, WI

Autumn Lake Healthcare At Beloit

3-star overall rating with 3-star inspections with 5 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle

2121 Pioneer Dr, Beloit, WI

(608) 365-9526

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

80

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Autumn Lake Healthcare

Operator or chain grouping

Approved since

2001-07-12

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.63

Registered nurse staffing

LPN hours / resident day

0.45

Licensed practical nurse staffing

Aide hours / resident day

1.73

Nurse aide staffing

Weekend hours

2.34

Weekend nurse staffing

RN turnover

14%

Annual RN turnover

Total nurse turnover

37%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 2.6
1.6
1 pts worse
1.9
0.7 pts worse
Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days 1.9
2.2
0.3 pts better
1.8
0.1 pts worse
Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 100.0%
95.7%
4.3 pts better
93.4%
6.6 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 100.0%
95.0%
5 pts better
95.5%
4.5 pts better
Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury 2.2%
3.2%
1 pts better
3.3%
1.1 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms 1.5%
5.0%
3.5 pts better
11.4%
9.9 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight 6.5%
4.9%
1.6 pts worse
5.4%
1.1 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication 15.9%
16.6%
0.7 pts better
19.6%
3.7 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication 24.9%
16.7%
8.2 pts worse
16.7%
8.2 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who were physically restrained 0.0%
0.1%
0.1 pts better
0.1%
0.1 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose ability to walk independently worsened 8.5%
21.1%
12.6 pts better
16.3%
7.8 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased 12.6%
17.3%
4.7 pts better
14.9%
2.3 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.4%
2.3%
1.9 pts better
1.0%
0.6 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection 4.5%
3.0%
1.5 pts worse
1.7%
2.8 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 28.6%
25.5%
3.1 pts worse
19.8%
8.8 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers 2.8%
5.5%
2.7 pts better
5.1%
2.3 pts better
Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 100.0%
86.8%
13.2 pts better
81.7%
18.3 pts better
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit 22.0%
15.0%
7 pts worse
12.0%
10 pts worse
Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication 3.7%
1.3%
2.4 pts worse
1.6%
2.1 pts worse
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 98.7%
82.2%
16.5 pts better
79.7%
19 pts better
Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission 27.2%
22.7%
4.5 pts worse
23.9%
3.3 pts worse
Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-09-25 · Fire 2024-09-25

5 health deficiencies

Top issue: Nursing and Physician Services (2 deficiencies)

9 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Cycle 2 Health 2023-06-29 · Fire 2023-06-29

4 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

11 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 3 Health 2022-04-13 · Fire 2022-04-13

11 health deficiencies

Top issue: Nutrition and Dietary (3 deficiencies)

5 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-09-25

E24 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures for volunteers.

Corrected 2024-10-18

F · Potential for more than minimal harm 2024-09-25

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-10-18

E · Potential for more than minimal harm 2024-09-25

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2024-10-18

E · Potential for more than minimal harm 2024-09-25

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-10-18

D · Potential for more than minimal harm 2024-09-25

K281 · Egress Deficiencies

Fire Safety

Install proper backup exit lighting.

Corrected 2024-10-18

D · Potential for more than minimal harm 2024-09-25

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-10-18

D · Potential for more than minimal harm 2024-09-25

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2024-10-18

C · Minimal harm 2024-09-25

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2024-10-18

C · Minimal harm 2024-09-25

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-10-18

F · Potential for more than minimal harm 2023-06-29

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-08-31

F · Potential for more than minimal harm 2023-06-29

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2024-02-26

F · Potential for more than minimal harm 2023-06-29

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-08-01

E · Potential for more than minimal harm 2023-06-29

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2023-08-01

E · Potential for more than minimal harm 2023-06-29

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2023-08-01

E · Potential for more than minimal harm 2023-06-29

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-08-01

E · Potential for more than minimal harm 2023-06-29

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-08-01

D · Potential for more than minimal harm 2023-06-29

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2023-08-01

D · Potential for more than minimal harm 2023-06-29

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2023-08-01

D · Potential for more than minimal harm 2023-06-29

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-08-01

D · Potential for more than minimal harm 2023-06-29

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2023-08-01

F · Potential for more than minimal harm 2022-04-13

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2022-05-11

F · Potential for more than minimal harm 2022-04-13

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2022-05-11

E · Potential for more than minimal harm 2022-04-13

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2022-06-09

E · Potential for more than minimal harm 2022-04-13

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2022-05-11

D · Potential for more than minimal harm 2022-04-13

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2022-05-11

Inspection history

Recent health citations

D · Potential for more than minimal harm 2026-01-06

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2026-01-30

D · Potential for more than minimal harm 2026-01-06

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2026-01-30

C · Minimal harm 2026-01-06

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2026-01-30

G · Actual harm 2025-11-25

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-12-17

G · Actual harm 2025-11-25

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-12-17

D · Potential for more than minimal harm 2023-12-21

F561 · Resident Rights Deficiencies

Health

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Corrected 2024-01-18

D · Potential for more than minimal harm 2023-12-21

F691 · Quality of Life and Care Deficiencies

Health

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Corrected 2024-01-18

F · Potential for more than minimal harm 2023-06-29

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-07-24

F · Potential for more than minimal harm 2023-06-29

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-07-24

D · Potential for more than minimal harm 2023-06-29

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-07-24

D · Potential for more than minimal harm 2023-06-29

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-07-24

F · Potential for more than minimal harm 2022-04-13

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2022-05-11

F · Potential for more than minimal harm 2022-04-13

F809 · Nutrition and Dietary Deficiencies

Health

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Corrected 2022-05-11

F · Potential for more than minimal harm 2022-04-13

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2022-05-11

F · Potential for more than minimal harm 2022-04-13

F882 · Infection Control Deficiencies

Health

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Corrected 2022-05-11

E · Potential for more than minimal harm 2022-04-13

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2022-05-11

E · Potential for more than minimal harm 2022-04-13

F839 · Administration Deficiencies

Health

Employ staff that are licensed, certified, or registered in accordance with state laws.

Corrected 2022-05-11

E · Potential for more than minimal harm 2022-04-13

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-05-11

D · Potential for more than minimal harm 2022-04-13

F660 · Resident Assessment and Care Planning Deficiencies

Health

Plan the resident's discharge to meet the resident's goals and needs.

Corrected 2022-05-11

D · Potential for more than minimal harm 2022-04-13

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2022-05-11

Penalties and ownership

What sits behind the stars

Ownership

A&R Stern Family Holdings, LLC

5% Or Greater Direct Ownership Interest · Organization

67% 1 facilities 2019-02-01
Stern, Aryeh

5% Or Greater Indirect Ownership Interest · Individual

67% 24 facilities 2019-02-01
Davis, Yehoshua

5% Or Greater Direct Ownership Interest · Individual

13% 2 facilities 2019-02-01
Stern, Aryeh

5% Or Greater Direct Ownership Interest · Individual

0% 24 facilities 2019-02-01
Stern, Samuel

Corporate Officer · Individual

0% 74 facilities 2019-02-01
Viken, Susan

W-2 Managing Employee · Individual

0% 1 facilities 2019-02-01

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Staffing
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Fines
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Fines
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#3

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2-star overall rating with 3-star inspections with 10 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle

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Fines
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