Ascension Living - Lakeshore at Siena
Ascension Living - Lakeshore at Siena operates 60 certified beds in RACINE, Wisconsin. Its Medicare and Medicaid certification dates to 1992-08-18. It averages 52.9 residents a day.
What harm was found in the violations cited at Ascension Living - Lakeshore at Siena?
CMS lists 57 health-inspection deficiencies for Ascension Living - Lakeshore at Siena since 2023-06-22, 47 of them in the three years to 2026-08-01: the highest scope-and-severity letter on record is H; the most recent health inspection was 2026-02-09.
| Survey date | Tag | Deficiency | Severity |
|---|---|---|---|
| 2026-02-09 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | H |
| 2026-02-09 | F0689, F0744 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | G |
| 2026-02-09 | F0606, F0842, F0865, F0868, F0880, F0881, F0882, F0944 | Not hire anyone with a finding of abuse, neglect, exploitation, or theft. / Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. / Have a plan that describes the process for conducting QAPI and QAA activities. / Have the Quality Assessment and Assurance group have the required members and meet at least quarterly / Provide and implement an infection prevention and control program. / Implement a program that monitors antibiotic use. / Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. / Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. | F |
| 2026-02-09 | F0657, F0684, F0755, F0761 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. / Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. / Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | E |
| 2026-02-09 | F0561, F0585, F0609, F0610, F0628, F0688, F0690, F0695, F0756, F0757, F0759 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. / Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. / Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / Respond appropriately to all alleged violations. / Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. / Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. / Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. / Provide safe and appropriate respiratory care for a resident when needed. / Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. / Ensure each resident’s drug regimen must be free from unnecessary drugs. / Ensure medication error rates are not 5 percent or greater. | D |
| 2026-02-09 | F0732 | Post nurse staffing information every day. | C |
| 2025-07-21 | F0610, F0692 | Respond appropriately to all alleged violations. / Provide enough food/fluids to maintain a resident's health. | D |
| 2025-05-30 | F0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D |
| 2025-02-11 | F0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D |
| 2024-12-26 | F0689, F0755 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D |
| 2024-09-23 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G |
| 2024-09-23 | F0908 | Keep all essential equipment working safely. | E |
| 2024-09-23 | F0563, F0578, F0600, F0609, F0610, F0745 | Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. / Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. / Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. / Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / Respond appropriately to all alleged violations. / Provide medically-related social services to help each resident achieve the highest possible quality of life. | D |
| 2024-04-17 | F0585, F0677, F0684 | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. / Provide care and assistance to perform activities of daily living for any resident who is unable. / Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D |
| 2024-01-23 | F0686, F0689 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D |
| 2023-10-05 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E |
| 2023-06-22 | F0641, F0755, F0867 | Ensure each resident receives an accurate assessment. / Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. / Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | E |
| 2023-06-22 | F0661, F0686, F0689, F0692, F0756, F0758 | Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. / Provide appropriate pressure ulcer care and prevent new ulcers from developing. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / Provide enough food/fluids to maintain a resident's health. / Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. / Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | D |
| 2023-06-22 | F0732 | Post nurse staffing information every day. | C |
Has Ascension Living - Lakeshore at Siena had payment denied by Medicare?
| Payment denial start | Length in days |
|---|---|
| 2024-10-26 | 19 |
How is Ascension Living - Lakeshore at Siena staffed?
| Measure | This facility | WI average |
|---|---|---|
| Total nurse staffing hours per resident per day | 4.70345 | 4.21234 |
| Total nursing staff turnover (%) | 73.3 | 46.9 |
| Average number of residents per day | 52.9 | 54.8 |
Who owns Ascension Living - Lakeshore at Siena, and what chain is it in?
Ascension Living - Lakeshore at Siena is registered with CMS as Non profit - Church related, operates under the legal business name ASCENSION LIVING - LAKESHORE AT SIENA INC and belongs to the ASCENSION LIVING chain.
| Role | Owner | Association date |
|---|---|---|
| 5% OR GREATER DIRECT OWNERSHIP INTEREST | ASCENSION HEALTH SENIOR CARE | since 07/01/2014 |
| CORPORATE DIRECTOR | MUSGRAVE, LISA, SHADBOLT, ERIN, SMOOT, KENNETH | since 01/01/2024 |
| CORPORATE OFFICER | SHADBOLT, ERIN | since 10/17/2022 |
| OPERATIONAL/MANAGERIAL CONTROL | AJAYI, OLUSOLA, SIDHU, SARFRAZ | since 05/01/2025 |
| ADP OF THE SNF | ASCENSION HEALTH SENIOR CARE, HEALTH DIMENSIONS CONSULTING INC, HOUSE HEALTHCARE SOLUTIONS LLC, INTELYCARE INC, MEDICAL SOLUTIONS LLC, METIS LTC LLC, PERSONNEL SPECIALISTS LLC, PROLINK HEALTHCARE LLC, AJAYI, OLUSOLA, MUSGRAVE, LISA, SHADBOLT, ERIN, SIDHU, SARFRAZ, SMOOT, KENNETH | since 01/01/2024 |
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