5 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Beloit, WI
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
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
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
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
| 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
Top issue: Nursing and Physician Services (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Quality of Life and Care (2 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Nutrition and Dietary (3 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2024-10-18
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-18
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
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-10-18
Fire Safety
Install proper backup exit lighting.
Corrected 2024-10-18
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-18
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-10-18
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-10-18
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-18
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-31
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-02-26
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-01
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
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-08-01
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-01
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-01
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
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
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-01
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-08-01
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-05-11
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-05-11
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-06-09
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
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-05-11
Inspection history
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
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
Health
Post nurse staffing information every day.
Corrected 2026-01-30
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-12-17
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-17
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
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2024-01-18
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
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-24
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-24
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-07-24
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
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
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
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2022-05-11
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-05-11
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2022-05-11
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-11
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2022-05-11
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-05-11
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Nearby options
Beloit, WI
1-star overall rating with 1-star inspections with $78,202 in total fines with 25 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
South Beloit, IL
4-star overall rating with 4-star inspections with $22,139 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
Clinton, WI
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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