Inspection Reports for Ascension Living Lakeshore at Siena
5643 ERIE ST, RACINE, WI, 53402
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 24, 2025, found no deficiencies and two complaints were unsubstantiated. Earlier inspections showed a pattern of deficiencies related mainly to incomplete resident records, resident care documentation, and medication management, with some substantiated complaints in May 2024 involving caregiver background checks, resident assessments, service plan updates, and medication disposal policies. Enforcement actions included a $500 forfeiture and a $200 inspection fee following the May 15, 2024, survey to address prior deficiencies. Complaint investigations were mostly unsubstantiated except for two substantiated complaints in May 2024 concerning medication orders and resident care issues. The trend suggests improvement over time, with the most recent inspection showing no deficiencies after previous issues were addressed.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
35% better than Wisconsin average
Wisconsin average: 4.6 deficiencies/year
Deficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
24 residents
Based on a November 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 24
Deficiencies: 0
Date: Nov 24, 2025
Visit Reason
Surveyor conducted two complaint investigations at Ascension Living Lakeshore at Siena.
Complaint Details
Two complaints were investigated and found to be unsubstantiated.
Findings
Two complaints were unsubstantiated and no deficiencies were identified.
Notice
Deficiencies: 0
Date: May 7, 2025
Visit Reason
Two complaint investigations were concluded to determine if Ascension Living Lakeshore at Siena was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
Two complaint investigations were concluded on May 7, 2025, resulting in issuance of a Statement of Deficiency #C68611 for violations found.
Findings
The Department issued a Statement of Deficiency for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, establishing grounds for regulatory action and requiring the licensee to comply with all requirements within 45 days.
Report Facts
Appeal timeframe: 10
Compliance timeframe: 45
Posting duration: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Beth Hoffman | Assisted Living Regional Director | Contact person for questions about the letter. |
| Kenneth Brotheridge | Assisted Living Director | Signed the notice letter. |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 1
Date: May 7, 2025
Visit Reason
Surveyor conducted 2 complaint investigations at Ascension Living Lakeshore at Siena to investigate complaints received.
Complaint Details
Two complaint investigations were conducted and found to be unsubstantiated.
Findings
The complaints were unsubstantiated. One deficiency was identified related to incomplete resident records for 3 residents, missing required documentation such as preadmission assessments, individualized service plans, health screenings, admission agreements, and evacuation assessments.
Deficiencies (1)
Resident records were not maintained with all required documentation for 3 of 3 residents reviewed, including missing preadmission assessments, individualized service plans, health screenings, admission agreements, and evacuation assessments.
Report Facts
Census: 28
Residents reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| House Manager A | Interviewed regarding missing resident records and stated lack of knowledge about documentation location and plans to maintain records going forward | |
| Nurse Manager A | Provided resident records to surveyor |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 0
Date: Dec 13, 2024
Visit Reason
Surveyor conducted a verification visit and one complaint investigation.
Complaint Details
One complaint was investigated and found to be unsubstantiated.
Findings
No deficiencies were identified. One complaint was unsubstantiated.
Report Facts
Revisit fee: 200
Inspection Report
Enforcement
Deficiencies: 0
Date: May 15, 2024
Visit Reason
A standard survey, verification visit, and two complaint investigations were conducted to determine if Ascension Living Lakeshore at Siena was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
Two complaint investigations were conducted as part of the visit; however, specific substantiation status or details are not provided in the document.
Findings
The Department issued a Statement of Deficiency (SOD #FDOC12) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a forfeiture of $500.00 and an imposed $200 inspection fee for a revisit to verify correction of prior deficiencies.
Report Facts
Forfeiture amount: 500
Reduced forfeiture amount: 325
Inspection fee: 200
Days to pay forfeiture: 10
Days to pay inspection fee: 10
Days to achieve compliance: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MaryBeth Hoffman | Assisted Living Regional Director | Contact person for questions about the letter |
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter |
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 5
Date: May 7, 2024
Visit Reason
Surveyor conducted a standard survey, verification visit, and two complaint investigations at Ascension Living Lakeshore at Siena, a Community-Based Residential Facility (CBRF) in Racine, WI, based on complaints received.
Complaint Details
Two of two complaints were substantiated. One complaint involved medication packs containing two different physician orders for Tylenol. Another complaint involved issues related to resident care and assessments.
Findings
Five deficiencies were identified, including failure to complete caregiver background checks, incomplete resident assessments after changes in condition, lack of signatures on individual service plans, failure to update service plans with changes in resident condition, and inadequate medication disposal documentation. Two complaints were substantiated.
Deficiencies (5)
Failure to ensure caregiver background check was completed for 1 of 2 employees reviewed.
Failure to assess resident's needs, abilities, and physical and mental condition for 1 of 1 resident reviewed when there was a change in condition.
Failure to have resident or legal representative sign the Individual Service Plan acknowledging involvement and agreement for 2 of 2 residents reviewed.
Failure to update Individual Service Plan to reflect changes in mobility status, wound care, and feeding assistance for 1 of 1 resident reviewed.
Failure to develop and implement a policy for disposing unused, discontinued, outdated, or recalled medications with proper documentation and witness signatures for 1 of 1 resident.
Report Facts
Deficiencies identified: 5
Revisit fee: 200
Resident census: 23
Tylenol dosage: 325
Tylenol dosage: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director A | Executive Director | Interviewed regarding caregiver background check and Individual Service Plan deficiencies. |
| Director of Clinical Services B | Director of Clinical Services | Interviewed regarding caregiver background check, assessments, service plans, and medication destruction. |
| Director of Nursing D | Director of Nursing | Acknowledged need for proper medication destruction documentation. |
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