Heritage Lakeside

In the surveyor’s words

From the most serious findings on record at Heritage Lakeside, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Mar 2, 2023

  Based on observation, interview and record review, the facility did not establish and implement an ongoing infection prevention and control program to prevent, recognize and control the onset and spread of infection to the extent possible as evidenced by the cumulative failures of the following. This had the potential to affect all 35 residents in the facility. The facility did not immediately implement precautions and resident isolation with a new onset Gastrointestinal illness (GI). The facility did not maintain ongoing, real-time surveillance within the facility to identify a GI outbreak or to identify other outbreaks. The facility did not post signage to inform staff and visitors of the new onset GI outbreak. […]

• Immediate jeopardy, isolatedF684Apr 8, 2026

  Based on observation, interview, and record review, the facility failed to ensure that each resident receives treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 of 12 residents (R) reviewed (R46.) Beginning 03/03/26, R46 presented with a change of condition including shortness of breath, difficulty breathing, and continuous use of a Continuous Positive Airway Pressure (CPAP) machine. The facility failed to assess R46 with the change in condition, failed to notify the provider of R46's change in condition, failed to complete respiratory assessments as per provider order, and failed to implement new care plan interventions. […]

• Immediate jeopardy, isolatedF684Sep 23, 2024

  Based on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice (N6 Wisconsin Nurse Practice Act), the comprehensive person-centered care plan, and the resident's choice for 1 of 13 sampled residents (R1). R1 had a change in condition; staff did not complete comprehensive neurological assessments or have a Registered Nurse assess R1 as the change of condition continued. R1 was sent to the emergency room several hours later and had suffered a stroke, and as a result was put on hospice services. The facility's failure to assess R1 and provide appropriate treatment for stroke symptoms created a finding of immediate jeopardy that began on [DATE]. […]

• Immediate jeopardy, isolatedF692Sep 23, 2024

  Based on observation, record review, and interview, the facility failed to ensure residents received adequate fluid and food intake to maintain acceptable parameters of hydration and nutrition for 3 of 3 residents (R) (R2, R1, R19). R2 was admitted to the facility on [DATE]. R2 was sent to hospital on 03/16/24 and returned on 03/23/24 with diagnosis of failure to thrive and laboratory results of elevated blood urea nitrogen (BUN) and creatinine indicating dehydration. R2 was hospitalized on [DATE] with elevated BUN, creatinine, and albumin levels, resulting in R2 being transferred to another critical care hospital and expiring on 05/27/24. […]

• Actual harm, patternF600Sep 1, 2022

  Based on observation, interview and record review, the facility did not ensure that residents were free from physical, emotional and mental abuse for 6 (R11, R12, R13, R14, R15, and R16) of 9 residents reviewed for abuse. *On 7/29/22, R7 attempted to climb into R11's bed. R11 pushed her table towards R7 and yelled for assistance. Staff came in and removed R7 from R11's room. *On 7/8/22, R7 entered R15's room. R7 punched R15 in the nose and face. R15 received a scratch on his nose due to the interaction. *On 6/28/22, R7 entered R16's room. R7 tried to grab R16's wheelchair and was grabbing at R16. R16 reported that R7 hit her in the head. *R14 stated R7 had entered her room on multiple occasions. R7 sat on R14 while R14 was in bed. R7 hit R14 on multiple occasions. […]