F
36/100Ascension Living - Lakeshore at Siena Inspection Report, Violations & Safety Grade (RACINE, Wisconsin)
5643 ERIE STREET, RACINE, Wisconsin 53402
Phone: 2628989100
CMS Overall:1/5
Overview & Bed Count
Certified Beds
60
Avg Residents/Day
40.4
Ownership
Non profit - Church related
Provider Type
Medicare and Medicaid
County
Racine
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall1/5
Health1/5
Staffing3/5
Quality2/5
Nurse Staffing Check
| Metric | This Facility | Wisconsin Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 1.16 | 0.98 | +0.17 |
| Total Nurse Hours per Resident per Day | 5.22 | 4.25 | +0.97 |
| CMS Staffing Rating | 3/5 | 3.7/5 | - |
| Nursing Staff Turnover | 77.7% | 46.7% | - |
Health Citation History
57 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-02-09 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | H – Actual Harm |
| 2026-02-09 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G – Actual Harm |
| 2026-02-09 | Quality of Life and Care Deficiencies | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | G – Actual Harm |
| 2026-02-09 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | F – Moderate Harm Potential |
| 2026-02-09 | Resident Assessment and Care Planning Deficiencies | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | F – Moderate Harm Potential |
| 2026-02-09 | Administration Deficiencies | Have a plan that describes the process for conducting QAPI and QAA activities. | F – Moderate Harm Potential |
| 2026-02-09 | Administration Deficiencies | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | F – Moderate Harm Potential |
| 2026-02-09 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | F – Moderate Harm Potential |
| 2026-02-09 | Infection Control Deficiencies | Implement a program that monitors antibiotic use. | F – Moderate Harm Potential |
| 2026-02-09 | Infection Control Deficiencies | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | F – Moderate Harm Potential |
| 2026-02-09 | Administration Deficiencies | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. | F – Moderate Harm Potential |
| 2026-02-09 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | E – Moderate Harm Potential |
| 2026-02-09 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | E – Moderate Harm Potential |
| 2026-02-09 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E – Moderate Harm Potential |
| 2026-02-09 | Pharmacy Service Deficiencies | 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 – Moderate Harm Potential |
| 2026-02-09 | Resident Rights Deficiencies | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | D – Moderate Harm Potential |
| 2026-02-09 | Resident Rights Deficiencies | 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. | D – Moderate Harm Potential |
| 2026-02-09 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2026-02-09 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | D – Moderate Harm Potential |
| 2026-02-09 | Resident Rights Deficiencies | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | D – Moderate Harm Potential |
| 2026-02-09 | Quality of Life and Care Deficiencies | 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. | D – Moderate Harm Potential |
| 2026-02-09 | Quality of Life and Care Deficiencies | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D – Moderate Harm Potential |
| 2026-02-09 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2026-02-09 | Pharmacy Service Deficiencies | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D – Moderate Harm Potential |
| 2026-02-09 | Pharmacy Service Deficiencies | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D – Moderate Harm Potential |
| 2026-02-09 | Pharmacy Service Deficiencies | Ensure medication error rates are not 5 percent or greater. | D – Moderate Harm Potential |
| 2026-02-09 | Nursing and Physician Services Deficiencies | Post nurse staffing information every day. | C – Minimal Harm Potential |
| 2025-07-21 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | D – Moderate Harm Potential |
| 2025-07-21 | Quality of Life and Care Deficiencies | Provide enough food/fluids to maintain a resident's health. | D – Moderate Harm Potential |
| 2025-05-30 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2025-02-11 | Resident Assessment and Care Planning Deficiencies | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D – Moderate Harm Potential |
| 2024-12-26 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2024-12-26 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2024-09-23 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G – Actual Harm |
| 2024-09-23 | Environmental Deficiencies | Keep all essential equipment working safely. | E – Moderate Harm Potential |
| 2024-09-23 | Resident Rights Deficiencies | Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | D – Moderate Harm Potential |
| 2024-09-23 | Resident Rights Deficiencies | 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. | D – Moderate Harm Potential |
| 2024-09-23 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D – Moderate Harm Potential |
| 2024-09-23 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2024-09-23 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | D – Moderate Harm Potential |
| 2024-09-23 | Quality of Life and Care Deficiencies | Provide medically-related social services to help each resident achieve the highest possible quality of life. | D – Moderate Harm Potential |
| 2024-04-17 | Resident Rights Deficiencies | 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. | D – Moderate Harm Potential |
| 2024-04-17 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2024-04-17 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2024-01-23 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D – Moderate Harm Potential |
| 2024-01-23 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2023-10-05 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E – Moderate Harm Potential |
| 2023-06-22 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | E – Moderate Harm Potential |
| 2023-06-22 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E – Moderate Harm Potential |
| 2023-06-22 | Administration Deficiencies | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | E – Moderate Harm Potential |
Showing 50 of 57 citations.
Fire Safety Citation History
28 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-02-09 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2026-02-09 | Miscellaneous Deficiencies | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | F – Moderate Harm Potential |
| 2026-02-09 | Smoke Deficiencies | Provide properly protected cooking facilities. | E – Moderate Harm Potential |
| 2026-02-09 | Smoke Deficiencies | Install smoke barrier doors that can resist smoke for at least 20 minutes. | E – Moderate Harm Potential |
| 2026-02-09 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | D – Moderate Harm Potential |
| 2026-02-09 | Miscellaneous Deficiencies | Have restrictions on the use of highly flammable decorations. | D – Moderate Harm Potential |
| 2026-02-09 | Miscellaneous Deficiencies | Have restrictions on the use of portable space heaters. | D – Moderate Harm Potential |
| 2026-02-09 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | D – Moderate Harm Potential |
| 2024-09-23 | Emergency Preparedness Deficiencies | Develop and maintain an Emergency Preparedness Program (EP). | F – Moderate Harm Potential |
| 2024-09-23 | Emergency Preparedness Deficiencies | Conduct testing and exercise requirements. | F – Moderate Harm Potential |
| 2024-09-23 | Smoke Deficiencies | Install a fire alarm system that can be heard throughout the facility. | F – Moderate Harm Potential |
| 2024-09-23 | Smoke Deficiencies | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | F – Moderate Harm Potential |
| 2024-09-23 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | F – Moderate Harm Potential |
| 2024-09-23 | Miscellaneous Deficiencies | Provide a written emergency evacuation plan. | F – Moderate Harm Potential |
| 2024-09-23 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2024-09-23 | Miscellaneous Deficiencies | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | F – Moderate Harm Potential |
| 2024-09-23 | Construction Deficiencies | Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | E – Moderate Harm Potential |
| 2024-09-23 | Egress Deficiencies | 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. | E – Moderate Harm Potential |
| 2024-09-23 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | E – Moderate Harm Potential |
| 2024-09-23 | Smoke Deficiencies | Install smoke barrier doors that can resist smoke for at least 20 minutes. | E – Moderate Harm Potential |
| 2024-09-23 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | D – Moderate Harm Potential |
| 2024-09-23 | Services Deficiencies | Have properly installed electrical wiring and gas equipment. | D – Moderate Harm Potential |
| 2024-09-23 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | D – Moderate Harm Potential |
| 2024-09-23 | Egress Deficiencies | Install emergency lighting that can last at least 1 1/2 hours. | C – Minimal Harm Potential |
| 2023-06-22 | Egress Deficiencies | 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. | E – Moderate Harm Potential |
| 2023-06-22 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper medical gas storage and administration areas. | E – Moderate Harm Potential |
| 2023-06-22 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | D – Moderate Harm Potential |
| 2023-06-22 | Gas, Vacuum, and Electrical Systems Deficiencies | Meet requirements for the use of electrical equipment. | D – Moderate Harm Potential |
Total Penalties & Fines
$218,735
Total Fine Amount (CMS)
1
Number of Fines
3
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2026-02-09 | Fine | $218,735 | - |
| 2026-02-09 | Payment Denial | - | 47 days starting 2026-03-11 |
| 2024-09-23 | Payment Denial | - | 19 days starting 2024-10-26 |
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Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the RACINE area at no cost.
Find Safe, Vetted Facilities Near RACINE
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.