Inspection Reports for
Ascension Living Lakeshore at Siena
5643 ERIE ST, RACINE, WI, 53402
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
11.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
157% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/year
Deficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
67% occupied
Based on a November 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate 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.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 21, 2025
Visit Reason
The inspection was conducted due to allegations of neglect and abuse reported by Adult Protective Services concerning two residents, R7 and R1, at Ascension Living - Lakeshore at Siena.
Complaint Details
The complaint investigation was triggered by an allegation of neglect reported by Adult Protective Services on 6/24/25 concerning Resident R7. The investigation was found incomplete and lacking proper interviews and documentation. Additionally, concerns about inadequate hydration monitoring for Resident R1 were substantiated.
Findings
The facility failed to conduct a thorough investigation of the neglect allegation involving Resident R7, lacking staff and resident interviews and proper documentation. Additionally, the facility did not ensure adequate fluid intake and hydration monitoring for Resident R1, who was hospitalized with dehydration and related complications.
Deficiencies (2)
F 0610: The facility did not ensure a thorough investigation was completed for the allegation of neglect of Resident R7 reported by Adult Protective Services on 6/24/25. The investigation lacked staff and resident interviews and sufficient documentation.
F 0692: The facility did not ensure Resident R1 received adequate fluid intake to maintain hydration. There was no documentation of fluid intake monitoring or hydration status assessments despite R1 being at risk for dehydration, leading to hospitalization.
Report Facts
Date of allegation report: Jun 24, 2025
Survey completion date: Jul 21, 2025
BIMS score: 10
BIMS score: 7
Potassium level: 6.8
Blood Urea Nitrogen (BUN): 127
Creatinine level: 14.27
Minimum fluid offered per meal: 480
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NHA-A | Nursing Home Administrator | Interviewed regarding the facility's investigation of neglect allegation for Resident R7 |
| CNA-C | Certified Nursing Assistant | Interviewed about Resident R1's condition and hydration concerns |
| RN-F | Registered Nurse, Unit Manager | Interviewed about Resident R1's condition and facility protocols for dehydration monitoring |
| DON-B | Director of Nursing | Interviewed regarding documentation of Resident R1's fluid intake and hydration monitoring |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 30, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a failure to timely report suspected abuse involving a Certified Nurse Aide and Resident 5.
Complaint Details
The complaint involved an allegation by Resident 5 that a Certified Nurse Aide refused to assist her to bed and was mean. The allegation was reviewed but the initial report submission to the State Survey Agency was not documented within the required two-hour timeframe.
Findings
The facility failed to provide evidence that an initial report of an abuse allegation was submitted to the State Survey Agency within two hours as required. The investigation revealed incomplete reporting documentation and no clear submission date or time for the abuse allegation report.
Deficiencies (1)
F 0609: The facility failed to timely report suspected abuse within two hours to the State Survey Agency for one of two residents reviewed for abuse. Documentation lacked evidence of submission date and time for the initial abuse report.
Report Facts
Residents reviewed for abuse: 2
Total sample size: 13
Incident ID: 1197928
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
Plan of Correction
Deficiencies: 1
Date: Feb 11, 2025
Visit Reason
The inspection was conducted to evaluate compliance with medical record maintenance and safeguarding resident-identifiable information standards.
Findings
The facility failed to ensure that one of three residents reviewed had a complete and accurate medical record due to lack of access to wound assessments from a previous contracted wound care provider after the contract ended.
Deficiencies (1)
F 0842 Safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards. The facility did not obtain wound assessments from the previous wound care provider, resulting in incomplete medical records for one resident.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | Named in relation to lack of access to wound assessments from previous wound care provider |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 26, 2024
Visit Reason
The inspection was conducted following complaints and concerns regarding resident safety related to falls and an incident involving a Hoyer lift transfer. The visit also reviewed medication administration accuracy for a resident.
Complaint Details
The complaint investigation involved resident R2 being struck by a Hoyer lift during transfer, resulting in a bloody lip. Staff involved included CNA-F, CNA-E, and LPN-G. Interviews revealed inconsistent reporting and lack of awareness of the incident by supervisory staff. The facility was also found to have incomplete fall risk assessments and medication administration documentation.
Findings
The facility failed to complete fall risk assessments after each fall for one resident and did not implement appropriate fall interventions. Staff did not report an incident where a resident was hit during a Hoyer lift transfer, preventing proper evaluation and intervention. Medication administration records for a resident were incomplete and inaccurate, with discrepancies between documented administrations and controlled drug logs.
Deficiencies (2)
F 0689: The facility did not ensure fall risk assessments were completed after each fall for resident R1, who sustained three falls. Staff failed to report an incident where resident R2 was hit in the lip during a Hoyer lift transfer, preventing evaluation and prevention of future accidents.
F 0755: The facility did not ensure medication administration records were complete and accurate for resident R2. The narcotic medication log indicated six administrations in November 2024, but the Medication Administration Record documented only two.
Report Facts
Falls sustained by R1: 3
Medication administrations documented in narcotic log: 6
Medication administrations documented in MAR: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA-F | Certified Nursing Assistant | Involved in Hoyer lift incident with resident R2 and interviewed regarding the event. |
| CNA-E | Certified Nursing Assistant | Involved in Hoyer lift incident with resident R2 and interviewed regarding the event. |
| LPN-G | Licensed Practical Nurse | Nurse working with CNAs during the Hoyer lift incident involving resident R2; interviewed about the incident. |
| DON-B | Director of Nursing | Interviewed regarding fall risk assessments, incident reporting, and medication administration discrepancies. |
| NHA-A | Nursing Home Administrator | Interviewed regarding concerns about fall interventions and incident reporting. |
| Director of Quality Assurance-C | Director of Quality Assurance | Interviewed regarding fall risk assessment policies and concerns about interventions for cognitively impaired resident. |
| LPN-D | Licensed Practical Nurse | Interviewed about narcotic medication counting and disposal procedures. |
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
Complaint Investigation
Deficiencies: 10
Date: Sep 23, 2024
Visit Reason
The inspection was conducted due to complaints and allegations of abuse, neglect, and improper care at the facility, including visitation restrictions, missing advance directives, injury of unknown origin, and equipment maintenance issues.
Complaint Details
The complaint investigation involved allegations of verbal and physical abuse by a resident's family member, neglect related to improper transfers and injury, failure to report abuse and neglect allegations timely, inadequate pressure ulcer care, and unsafe equipment conditions. The facility substantiated some abuse allegations but failed to conduct thorough investigations or timely reporting. Visitation restrictions were imposed without proper assessment or family communication.
Findings
The facility was found to have restricted visitation without proper assessment or family communication, failed to maintain signed Do Not Resuscitate (DNR) orders for residents, did not prevent abuse or neglect including improper transfer causing injury, failed to timely report abuse allegations, did not conduct thorough investigations of abuse/neglect allegations, did not provide adequate pressure ulcer care, and had malfunctioning dishwashing equipment posing safety hazards.
Deficiencies (10)
F 0563: The facility restricted a resident's family member to supervised visitation without developing strategies to ensure safe and enjoyable visits, and failed to communicate visitation restrictions with the family.
F 0578: The facility did not ensure Do Not Resuscitate (DNR) orders were present in the medical records for 2 residents, despite policy requiring signed forms.
F 0600: A resident was transferred using a Hoyer lift with only one staff member instead of two as required, resulting in a bruise to the resident's forearm.
F 0609: The facility failed to timely report three allegations of abuse/neglect involving a resident to the Nursing Home Administrator and State Agency within required timeframes.
F 0610: The facility did not ensure residents were free from abuse and neglect, including failure to follow care plans and investigate injuries of unknown origin.
F 0610 (continued): Registered Nurse failed to report neglect allegations, and the facility did not investigate or report alleged neglect of a resident left up in a wheelchair for 40 hours.
F 0610 (continued): The facility did not ensure a thorough investigation of verbal and physical abuse allegations involving a resident and family member.
F 0686: The facility did not provide appropriate pressure ulcer care and failed to complete timely assessments and care plan revisions for a resident's pressure injuries.
F 0745: The facility did not provide medically-related social services to assess and monitor the impact of visitation restrictions on a resident's psychosocial well-being.
F 0908: Two dishwashing machines in the facility were leaking water onto the floor and one lacked a temperature display, creating a potential hazard and risk of improper sanitation.
Report Facts
Residents reviewed for abuse/neglect: 4
Residents reviewed for advance directives: 13
Residents reviewed for pressure injuries: 4
Residents affected by deficiencies: 1
Residents affected by deficiencies: 2
Residents affected by deficiencies: 1
Residents affected by deficiencies: 1
Dishwashing machines inspected: 3
Dishwashing machines leaking: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator-A | Nursing Home Administrator | Named in visitation restriction and abuse investigation findings |
| Director of Nursing-B | Director of Nursing | Named in advance directive and abuse investigation findings |
| Social Worker-C | Social Worker | Named in visitation restriction and psychosocial assessment findings |
| Registered Nurse-G | Registered Nurse | Named in neglect reporting failure and abuse allegation findings |
| Certified Nursing Assistant-J | Certified Nursing Assistant | Witnessed abuse and failed to report timely |
| Certified Nursing Assistant-V | Certified Nursing Assistant | Witnessed abuse |
| Director of Facilities-E | Director of Facilities | Named in dishwasher maintenance findings |
| Registered Nurse Unit Manager-I | Registered Nurse Unit Manager | Named in pressure ulcer care findings |
| Wound MD-Q | Wound Medical Doctor | Named in pressure ulcer care findings |
| Certified Occupational Therapy Assistant-L | Certified Occupational Therapy Assistant | Named in pressure ulcer care findings |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Sep 23, 2024
Visit Reason
The inspection was conducted due to complaints and allegations of abuse, neglect, and improper care at the facility, including visitation restrictions, physical abuse, neglect in care, and equipment safety concerns.
Complaint Details
The complaint investigation involved allegations of verbal and physical abuse by a resident's family member, neglect related to improper transfers and prolonged wheelchair use, failure to report abuse allegations timely, inadequate investigation of abuse and neglect, and unsafe equipment conditions. Some allegations were substantiated, including abuse and neglect, while others were not fully investigated or reported.
Findings
The facility was found to have restricted visitation without proper assessment or communication, failed to prevent abuse and neglect including improper transfer causing injury, did not timely report allegations of abuse, failed to provide appropriate pressure ulcer care, and did not maintain essential equipment properly.
Deficiencies (7)
F563: The facility restricted a resident's family member to supervised visitation without developing strategies to ensure safe and enjoyable visits, and failed to communicate visitation changes with the resident's family.
F600: The facility failed to prevent physical abuse when a resident was transferred using a Hoyer lift by only one staff member instead of two as required, resulting in a bruise.
F609: The facility did not timely report three allegations of abuse/neglect involving a resident to the Nursing Home Administrator or State Agency within required timeframes.
F610: The facility failed to conduct a thorough investigation of abuse and neglect allegations, including verbal abuse and neglect related to a resident being left up in a wheelchair for 40 hours.
F686: The facility did not ensure appropriate pressure ulcer care and failed to revise care plans or complete comprehensive assessments timely for a resident with pressure injuries on both heels.
F745: The facility did not provide medically-related social services to assess or monitor the impact of visitation restrictions on a resident's psychosocial well-being.
F908: The facility did not maintain two dishwashing machines properly; they leaked water onto the floor and one lacked a temperature display, posing a safety hazard.
Report Facts
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents affected: 1
Dishwashers: 3
Dishwashers leaking: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator-A | Nursing Home Administrator | Named in visitation restriction and abuse investigation findings |
| Director of Nurses-B | Director of Nursing | Named in abuse and neglect investigation findings |
| Social Worker-C | Social Worker | Interviewed regarding visitation restrictions and psychosocial assessment |
| Registered Nurse-G | Registered Nurse | Failed to report neglect allegation |
| Certified Nursing Assistant-S | CNA | Involved in improper transfer causing resident injury |
| Director of Facilities-E | Director of Facilities | Interviewed regarding dishwasher maintenance issues |
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. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Apr 17, 2024
Visit Reason
The inspection was conducted to investigate multiple grievances filed by residents and their representatives regarding inadequate assistance with activities of daily living, including showering and dressing, and failure to follow physician orders for weekly weights.
Complaint Details
The investigation was triggered by grievances filed by residents and their representatives concerning lack of timely showers, dressing assistance, and failure to follow physician orders for weekly weights. The grievances were substantiated with findings of inadequate care and deficient grievance follow-up.
Findings
The facility failed to promptly resolve grievances related to residents not receiving timely showers or assistance with dressing. Additionally, one resident did not receive weekly weights as ordered by the physician for eleven weeks. Documentation of grievance investigations lacked summaries, conclusions, and follow-up actions.
Deficiencies (3)
F 0585: The facility did not make prompt efforts to resolve grievances for four residents who reported not receiving timely showers or assistance with dressing. Grievance documentation lacked summaries of findings, confirmation of receipt, follow-up, and dates of written decisions.
F 0677: The facility did not ensure one resident received required assistance with activities of daily living, specifically weekly showers/baths, as per the care plan. The resident only received one shower during several weeks and refused some showers.
F 0684: The facility failed to obtain weekly weights for one resident as ordered by the physician for eleven weeks, despite the resident being at risk for weight loss and having a documented significant weight decrease.
Report Facts
Residents affected: 4
Residents affected: 1
Residents affected: 1
Missed weekly weights: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SSD-C | Social Service Director and Grievance Officer | Named as grievance officer responsible for grievance process and follow-up |
| NHA-A | Nursing Home Administrator | Informed of grievance issues and signs off on grievance forms |
| DON-B | Director of Nursing | Informed of grievance findings and interviewed regarding resident care |
| CDM-C | Certified Dietician Manager | Interviewed regarding weight monitoring practices |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 23, 2024
Visit Reason
The inspection was conducted to investigate complaints related to pressure ulcer care and fall prevention at the facility.
Complaint Details
The complaint investigation focused on pressure ulcer care deficiencies for one resident and inadequate fall prevention and investigation for two residents. The facility failed to properly assess wounds, obtain timely treatment orders, and thoroughly investigate falls or implement effective prevention strategies.
Findings
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers for one resident, and did not thoroughly investigate falls or implement adequate preventative interventions for two residents. Deficiencies included incomplete wound assessments, delayed treatment orders, and inadequate fall investigations.
Deficiencies (2)
F 0686: The facility did not ensure necessary treatment and services were provided to prevent and promote healing of pressure injuries for one resident. Wounds were not thoroughly assessed upon admission and treatment orders were delayed.
F 0689: The facility did not ensure two residents received necessary services to prevent falls/accidents. Fall investigations lacked thoroughness, did not identify root causes, and failed to implement effective preventative interventions.
Report Facts
Residents affected: 1
Residents affected: 2
Wound measurements: 6.14
Wound measurements: 3.8
Wound measurements: 0.1
Wound measurements: 5.9
Wound measurements: 8.1
Wound measurements: 0.1
Wound measurements: 1.3
Wound measurements: 2.7
Wound measurements: 0.1
Wound measurements: 1.6
Wound measurements: 2.7
Wound measurements: 0.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON-B | Director of Nursing | Interviewed regarding wound care deficiencies and fall investigations |
| RN-F | Registered Nurse | Measured and documented wounds for resident R3 |
| Wound RN-H | Wound Registered Nurse | Assessed wounds and provided treatment documentation |
| Wound MD-I | Wound Medical Doctor | Clarified wound staging and treatment orders |
| NHA-A | Nursing Home Administrator | Interviewed regarding fall investigations and family involvement |
| CNA-E | Certified Nursing Assistant | Reported family transferring resident and lack of staff intervention |
| CNA-J | Certified Nursing Assistant | Witnessed resident fall and assisted with lifting resident |
| RN-K | Registered Nurse | Responded to resident fall and coordinated hospital transfer |
| PT-C | Physical Therapist | Observed family transferring resident and advised staff |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 5, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure medications were available and administered to residents upon readmission following hospitalization.
Complaint Details
The complaint investigation found that medications were not available for administration to residents R1 and R2 upon readmission on 09/30/23. The pharmacy had the residents listed as inactive and did not deliver medications. The issue was confirmed by nurse interviews and review of interdisciplinary notes.
Findings
The facility failed to provide medications for two residents upon readmission after hospitalization, resulting in missed medication administrations on multiple days. The pharmacy had the residents listed as inactive, causing delays in medication delivery, and no policy was provided regarding admission/readmission orders.
Deficiencies (1)
F 0755: The facility failed to provide pharmaceutical services to meet the needs of residents R1 and R2 upon readmission, resulting in multiple medications not administered on 10/01/23 and 10/02/23 due to unavailability.
Report Facts
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN1 | Registered Nurse | Called pharmacy on 10/02/23 to inquire about missing medications for residents R1 and R2 |
| Clinical Nurse Manager | Clinical Nurse Manager | Interviewed on 10/05/23 regarding medication delivery and admission orders |
Inspection Report
Deficiencies: 1
Date: Jun 22, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with discharge planning and communication requirements for residents being discharged from the nursing home.
Findings
The facility failed to ensure that two discharged residents had complete discharge summaries including pertinent information, final status, and post-discharge plans. Documentation and referrals for home health services were incomplete or missing, and discharge forms were not fully completed or audited.
Deficiencies (1)
F 0661: The facility did not ensure that 2 out of 2 discharged residents had discharge summaries including all pertinent information, final status, and post-discharge plans. One resident lacked necessary home health referrals and the other had incomplete discharge documentation.
Report Facts
Residents affected: 2
Date of survey completed: Jun 22, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker-D | Interviewed regarding discharge planning and documentation for residents R302 and R51 | |
| Director of Quality-C | Interviewed about discharge process responsibilities and documentation | |
| Nursing Home Administrator (NHA)-A | Interviewed about discharge process oversight and audit responsibilities |
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Jun 22, 2023
Visit Reason
The survey was conducted as a recertification annual inspection to assess compliance with federal regulations including Minimum Data Set (MDS) accuracy, resident care, medication management, and quality assurance.
Findings
The facility had multiple deficiencies including incomplete and inaccurate MDS assessments due to lack of CNA charting, failure to provide complete discharge summaries, inadequate pressure ulcer care, insufficient individualized fall interventions, unaddressed significant weight loss in residents, missing daily nurse staffing postings, expired medications in medication rooms, delayed physician review of pharmacy recommendations, and lack of behavior monitoring for psychotropic medications.
Deficiencies (10)
F0641: The facility did not ensure 11 residents had complete and accurate MDS assessments due to missing sections and inaccurate functional status coding caused by incomplete CNA charting.
F0661: The facility failed to ensure discharge summaries for 2 residents included all pertinent information and post-discharge plans, resulting in incomplete communication to residents and receiving providers.
F0686: The facility did not provide timely comprehensive assessment and treatment for a stage 3 pressure ulcer on a resident readmitted with the wound, delaying physician notification and RN reassessment.
F0689: The facility failed to provide individualized fall interventions and adequate supervision for 2 residents, including lack of toileting care plans and bowel/bladder assessments.
F0692: The facility did not update care plans or implement additional interventions for 2 residents with significant weight loss, nor consistently monitor meal and supplement intake.
F0732: The facility failed to post daily nurse staffing information consistently, missing postings on multiple days including survey days.
F0755: Expired medications were found in two medication rooms, including antacid and melatonin, posing risk to residents.
F0756: The facility did not ensure timely physician review and documentation of pharmacy recommendations for a resident's psychotropic medication, with repeated recommendations ignored for five months.
F0758: The facility failed to monitor behavior and mood for a resident on two antidepressants, lacking behavior monitoring orders and documentation.
F0867: The facility's Quality Assurance Program did not have a system to measure or track the success of improvements addressing inaccurate and incomplete MDS assessments caused by lack of CNA charting.
Report Facts
Weight loss percentage: 7.7
Weight loss percentage: 7.8
Fall risk score: 24
Fall risk score: 36
Fall risk score: 9
Expired medication count: 5
Pharmacy recommendation repeat count: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Supervisor-E | MDS Supervisor | Named in relation to missing and inaccurate MDS assessments and CNA charting issues. |
| Nursing Home Administrator-A | Nursing Home Administrator | Named in relation to awareness of MDS issues, discharge process, and pharmacy recommendation follow-up. |
| Social Worker-D | Social Worker | Named in relation to MDS assessment completion and discharge planning. |
| Director of Quality-C | Director of Quality | Named in relation to medication room observations and QAPI discussions. |
| RN-C | Registered Nurse Director of Nursing | Named in relation to MDS assessment issues, pharmacy recommendation follow-up, and QAPI. |
| NP-G | Nurse Practitioner | Named in relation to pharmacy recommendation and medication discontinuation. |
| RD-L | Registered Dietician | Named in relation to nutritional assessments and weight loss monitoring. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 5, 2023
Visit Reason
Annual survey inspection of Ascension Living - Lakeshore at Siena nursing home to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 23, 2022
Visit Reason
The inspection was conducted due to concerns about medication error rates potentially exceeding 5 percent in the facility.
Complaint Details
The visit was complaint-related due to concerns about medication error rates. The medication error rate was substantiated at 6.25%, exceeding the 5% threshold.
Findings
The facility did not ensure it was free of medication errors, with 2 errors occurring during 32 medication administration opportunities, resulting in a 6.25% medication error rate affecting one resident. Errors included administering a medication without a physician order and giving a medication after a meal instead of before as ordered.
Deficiencies (1)
F 0759: The facility failed to ensure medication error rates were below 5 percent. Two medication errors occurred during 32 opportunities, including administering TUMS without a physician order and giving pantoprazole after the resident had eaten instead of before as ordered.
Report Facts
Medication administration opportunities: 32
Medication errors: 2
Medication error rate: 6.25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN-C | Licensed Practical Nurse | Administered medications incorrectly including giving TUMS without order and pantoprazole after meal |
| CM-D | Clinical Manager | Verified medication administration expectations and confirmed medication errors |
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