Heritage Lakeside
Inspection Findings
F-Tag F0656
F 0656 Level of Harm - Minimal harm or potential for actual harm
cushion.Surveyor reviewed the care plan and there was no mention of Resident R1's preference to sit on multiple items in the wheelchair, and no mention of the lumbar back support that was used.Example 3Surveyor reviewed Resident R1's physicians orders. Order was received on 09/26/25 that reads, in part, Patient may bear weight on right foot in CAM boot.Surveyor reviewed Resident R1's chart and found no mention of the use of a CAM boot in Resident R1's care plan nor on the CNA Kardex.
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
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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
10/07/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Lakeside
1016 Lakeshore Dr Rice Lake, WI 54868
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-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility did not ensure resident's environment was free from accidental hazards to prevent accidents for 1 of 3 residents reviewed.Resident R1 was sitting on multiple items in a wheelchair, which contributed to Resident R1 falling off the wheelchair seat during transport.Findings:According to Nemt Insurance article, dated 05/01/21, It is perfectly acceptable that additional cushioning may be an integral component to a wheelchair user's level of comfort. However, the cushion should be specifically designed by the manufacturer and integrated into the original design of the wheelchair by that manufacturer. If it isn't, then it should be removed from the wheelchair prior to transport in an effort to reduce the likelihood of severe injury if an accident were to occur. While a passenger's personal comfort is important; ultimately their safety, and the safety of those around them is more important.Resident R1 was admitted to
the facility on [DATE REDACTED], with diagnoses that include a stroke affecting the right side of body and morbidly obese. Resident R1's Minimum Data Set (MDS) dated [DATE REDACTED] indicated Resident R1 has no cognitive impairment, understands, and is understood. Resident R1 requires maximum assistance with bed mobility and is dependent on staff for transfers, toileting, and mobility once in a wheelchair.Surveyor reviewed the incident report that notes on 09/16/25, Resident R1 was being transported to an appointment in wheelchair via van service. Certified Nursing Assistant (CNA) C accompanied Resident R1. During the transport, driver applied brakes to avoid hitting a deer, which led to Resident R1 falling off the seat of the wheelchair and onto the foot pedals. On 10/07/25 at 10:06 AM, Surveyor interviewed CNA C. CNA C stated Resident R1 was sitting on a dycem, cushion, and bath blanket to
the best of her knowledge. When the driver applied the brakes, Resident R1 slid under the safety belts and landed on
the wheelchair foot pedals. Resident R1's right foot got pinned between the wheelchair wheel and the seat belt device on the floor of the transportation van. CNA C and the van driver attempted to assist Resident R1 but was unable. Van driver called 911. Paramedics arrived and lifted Resident R1 up as another moved the wheelchair out from under Resident R1 and lowered to the floor. From there the paramedics used a sheet to place Resident R1 on a stretcher and transported to the hospital via ambulance.Surveyor reviewed Resident R1's hospital records, dated 09/16/25, which identified Resident R1 acquired a right ankle fracture. Resident R1 was treated and sent back to the facility with follow up orders.On 10/07/25, Surveyor interviewed Director of Nursing (DON) B and asked if having Resident R1 sit on multiple items in the wheelchair during transport contributed to a hazard. DON B said it could have been a possibility, or the driver could have also strapped the belt over the top of the abdomen instead of under it.
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HERITAGE LAKESIDE in RICE LAKE, WI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in RICE LAKE, WI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from HERITAGE LAKESIDE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.