Heritage Lakeside: Care Plan Failures Flagged - WI
The Kardex is the working document that nursing aides carry into a room. It tells them, in plain terms, what a resident needs and how to help safely. If a resident can only bear weight in a specific boot, the Kardex is where that information lives. At Heritage Lakeside, it didn't.
That gap matters in a specific, physical way. A certified nursing assistant helping the resident stand, transfer, or move through the facility had no documented instruction that a boot was required. Whether the boot was being used consistently, whether aides even knew it existed, the inspection record does not say. What it says is that the care plan was silent, and so was the Kardex.
The same inspection turned up two other documentation failures involving the same resident.
Inspectors found that the resident had a preference for sitting on multiple items in their wheelchair, an arrangement that affects positioning, comfort, and pressure distribution. That preference was not recorded in the care plan. A lumbar back support was also in use. That wasn't recorded either.
These are not abstract record-keeping problems. Care plans exist because residents in nursing facilities often have complex and layered needs, and the people providing hands-on care rotate. A night aide is not the same person as the morning aide. A weekend staff member may have no direct knowledge of what a resident prefers or requires. The care plan bridges that gap. When it's incomplete, the bridge is out.
Heritage Lakeside, located at 1016 Lakeshore Drive in Rice Lake, was cited under F0656, which covers the requirement that facilities develop and keep current a comprehensive care plan for each resident. Inspectors rated the level of harm as minimal harm or potential for actual harm, and noted that few residents were affected.
The citation came from a complaint inspection, meaning someone, whether a resident, family member, or staff, had raised a concern that prompted the visit. The inspection record does not identify who filed the complaint or what specifically triggered it.
What the record does show is a pattern within a single resident's file: a physician order that didn't reach the care plan, a seating preference that wasn't documented, a piece of equipment in active use that nobody had written down. Three separate things that staff needed to know, and three separate places where the documentation stopped short.
The resident is identified only as R1 throughout the inspection record.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Heritage Lakeside from 2025-10-07 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 10, 2026 · Our methodology
HERITAGE LAKESIDE in RICE LAKE, WI was cited for violations during a health inspection on October 7, 2025.
The Kardex is the working document that nursing aides carry into a room.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.