Ascension Living - Lakeshore At Siena

Penalties

• Sep 23, 2024 — Payment Denial · payment denial 19 days

Inspection findings

1. Feb 9, 2026 Health · 35 findings
   • Not serious Scope/severity D

     F0561 Resident Rights Deficiencies

     Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

     Corrected Mar 31, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0585 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.

     Corrected Mar 31, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0606 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

     Corrected Mar 31, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Mar 31, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Mar 31, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0628 Resident Rights Deficiencies

     Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

     Corrected Mar 31, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0657 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.

     Corrected Mar 31, 2026 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Mar 31, 2026 · CMS health inspection

   • Serious Scope/severity H

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Apr 27, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0688 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.

     Corrected Mar 31, 2026 · CMS health inspection

   • Serious Scope/severity G Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Apr 27, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0690 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.

     Corrected Mar 31, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Mar 31, 2026 · CMS health inspection

   • Not serious Scope/severity C Complaint

     F0732 Nursing and Physician Services Deficiencies

     Post nurse staffing information every day.

     Corrected Mar 31, 2026 · CMS health inspection

   • Serious Scope/severity G

     F0744 Quality of Life and Care Deficiencies

     Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

     Corrected Mar 31, 2026 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Mar 31, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0756 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.

     Corrected Mar 31, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0757 Pharmacy Service Deficiencies

     Ensure each resident’s drug regimen must be free from unnecessary drugs.

     Corrected Mar 31, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Mar 31, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0761 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.

     Corrected Mar 31, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0842 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.

     Corrected Mar 31, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0865 Administration Deficiencies

     Have a plan that describes the process for conducting QAPI and QAA activities.

     Corrected Mar 31, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0868 Administration Deficiencies

     Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

     Corrected Mar 31, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Mar 31, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0881 Infection Control Deficiencies

     Implement a program that monitors antibiotic use.

     Corrected Mar 31, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0882 Infection Control Deficiencies

     Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

     Corrected Mar 31, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0944 Administration Deficiencies

     Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

     Corrected Mar 31, 2026 · CMS health inspection

   • Not serious Scope/severity E

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Mar 10, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Mar 10, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     Corrected Mar 20, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Mar 10, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0753 Miscellaneous Deficiencies

     Have restrictions on the use of highly flammable decorations.

     Corrected Mar 10, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0761 Miscellaneous Deficiencies

     To conduct inspection, testing and maintenance of fire doors by qualified individuals.

     Corrected Apr 3, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0781 Miscellaneous Deficiencies

     Have restrictions on the use of portable space heaters.

     Corrected Mar 10, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Mar 10, 2026 · CMS fire safety

2. Jul 21, 2025 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Aug 8, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected Aug 8, 2025 · CMS health inspection

3. May 30, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Jun 19, 2025 · CMS health inspection

4. Feb 11, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0842 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.

     Corrected Mar 7, 2025 · CMS health inspection

5. Dec 26, 2024 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jan 21, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Jan 21, 2025 · CMS health inspection

6. Sep 23, 2024 Fire Safety · 24 findings
   • Not serious Scope/severity F

     E0004 Emergency Preparedness Deficiencies

     Develop and maintain an Emergency Preparedness Program (EP).

     Corrected Oct 19, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0039 Emergency Preparedness Deficiencies

     Conduct testing and exercise requirements.

     Corrected Oct 23, 2024 · CMS fire safety

   • Not serious Scope/severity D Complaint

     F0563 Resident Rights Deficiencies

     Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

     Corrected Nov 1, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0578 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.

     Corrected Nov 1, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0600 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.

     Corrected Oct 23, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Nov 1, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Nov 1, 2024 · CMS health inspection

   • Serious Scope/severity G Complaint

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Oct 23, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0745 Quality of Life and Care Deficiencies

     Provide medically-related social services to help each resident achieve the highest possible quality of life.

     Corrected Nov 1, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0908 Environmental Deficiencies

     Keep all essential equipment working safely.

     Corrected Oct 23, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0132 Construction Deficiencies

     Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.

     Corrected Oct 23, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected Oct 23, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0222 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.

     Corrected Oct 21, 2024 · CMS fire safety

   • Not serious Scope/severity C

     K0291 Egress Deficiencies

     Install emergency lighting that can last at least 1 1/2 hours.

     Corrected Oct 16, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Oct 23, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0341 Smoke Deficiencies

     Install a fire alarm system that can be heard throughout the facility.

     Corrected Nov 14, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0354 Smoke Deficiencies

     Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

     Corrected Oct 23, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     Corrected Oct 23, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Oct 23, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Oct 29, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0711 Miscellaneous Deficiencies

     Provide a written emergency evacuation plan.

     Corrected Oct 23, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Oct 23, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0761 Miscellaneous Deficiencies

     To conduct inspection, testing and maintenance of fire doors by qualified individuals.

     Corrected Oct 23, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Oct 21, 2024 · CMS fire safety

7. Apr 17, 2024 Health · 3 findings
   • Not serious Scope/severity D Complaint

     F0585 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.

     Corrected May 14, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected May 14, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected May 14, 2024 · CMS health inspection

8. Jan 23, 2024 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Mar 7, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Mar 7, 2024 · CMS health inspection

9. Oct 5, 2023 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Nov 9, 2023 · CMS health inspection

10. Jun 22, 2023 Health · 14 findings
    • Not serious Scope/severity E

      F0641 Resident Assessment and Care Planning Deficiencies

      Ensure each resident receives an accurate assessment.

      Corrected Aug 7, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0661 Resident Assessment and Care Planning Deficiencies

      Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

      Corrected Jul 26, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0686 Quality of Life and Care Deficiencies

      Provide appropriate pressure ulcer care and prevent new ulcers from developing.

      Corrected Jul 20, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0689 Quality of Life and Care Deficiencies

      Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

      Corrected Jul 26, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0692 Quality of Life and Care Deficiencies

      Provide enough food/fluids to maintain a resident's health.

      Corrected Jul 26, 2023 · CMS health inspection

    • Not serious Scope/severity C

      F0732 Nursing and Physician Services Deficiencies

      Post nurse staffing information every day.

      Corrected Jul 15, 2023 · CMS health inspection

    • Not serious Scope/severity E

      F0755 Pharmacy Service Deficiencies

      Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

      Corrected Jul 26, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0756 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.

      Corrected Jul 20, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0758 Pharmacy Service Deficiencies

      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.

      Corrected Jul 26, 2023 · CMS health inspection

    • Not serious Scope/severity E

      F0867 Administration Deficiencies

      Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

      Corrected Jul 20, 2023 · CMS health inspection

    • Not serious Scope/severity E

      K0222 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.

      Corrected Jun 21, 2023 · CMS fire safety

    • Not serious Scope/severity D

      K0321 Smoke Deficiencies

      Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

      Corrected Jul 11, 2023 · CMS fire safety

    • Not serious Scope/severity D

      K0919 Gas, Vacuum, and Electrical Systems Deficiencies

      Meet requirements for the use of electrical equipment.

      Corrected Jun 21, 2023 · CMS fire safety

    • Not serious Scope/severity E

      K0923 Gas, Vacuum, and Electrical Systems Deficiencies

      Have proper medical gas storage and administration areas.

      Corrected Jul 11, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• AJAYI, OLUSOLA — adp of the snf, NOT APPLICABLE, since 05/19/2025
• AJAYI, OLUSOLA — operational/managerial control, NOT APPLICABLE, since 05/19/2025
• MUSGRAVE, LISA — corporate director, NOT APPLICABLE, since 01/01/2024
• MUSGRAVE, LISA — adp of the snf, NOT APPLICABLE, since 01/01/2024
• SHADBOLT, ERIN — corporate officer, NOT APPLICABLE, since 10/17/2022
• SHADBOLT, ERIN — corporate director, NOT APPLICABLE, since 01/01/2024
• SHADBOLT, ERIN — adp of the snf, NOT APPLICABLE, since 01/01/2024
• SIDHU, SARFRAZ — operational/managerial control, NOT APPLICABLE, since 05/01/2025
• SIDHU, SARFRAZ — adp of the snf, NOT APPLICABLE, since 05/01/2025
• SMOOT, KENNETH — adp of the snf, NOT APPLICABLE, since 01/01/2024
• SMOOT, KENNETH — corporate director, NOT APPLICABLE, since 01/01/2024
• ASCENSION HEALTH SENIOR CARE — 5% or greater direct ownership interest, 100%, since 07/01/2014
• ASCENSION HEALTH SENIOR CARE — adp of the snf, NOT APPLICABLE, since 07/14/2015
• HEALTH DIMENSIONS CONSULTING INC — adp of the snf, NOT APPLICABLE, since 08/02/2019
• HOUSE HEALTHCARE SOLUTIONS LLC — adp of the snf, NOT APPLICABLE, since 06/10/2025
• INTELYCARE INC — adp of the snf, NOT APPLICABLE, since 02/08/2022
• MEDICAL SOLUTIONS LLC — adp of the snf, NOT APPLICABLE, since 06/14/2017
• METIS LTC LLC — adp of the snf, NOT APPLICABLE, since 09/02/2024
• PERSONNEL SPECIALISTS LLC — adp of the snf, NOT APPLICABLE, since 04/10/2025
• PROLINK HEALTHCARE LLC — adp of the snf, NOT APPLICABLE, since 04/26/2023