Ascension Living - Lakeshore At Siena
Racine, Racine County, Wisconsin · CCN 525495 · Non-profit (Church related) · part of Ascension Living (12 facilities, chain average 2.8 stars)
CMS rates Ascension Living - Lakeshore At Siena 1 of 5 overall as of August 2026. 60 certified beds, 53 residents a day on average. 57 citations on record from the current inspection cycles, 4 involving actual harm; no fines on record and 1 payment denial.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★☆☆☆☆ 1 of 5 |
|---|---|
| Health inspections | ★☆☆☆☆ 1 of 5 |
| Staffing | ★★★☆☆ 3 of 5 |
| Quality measures | ★★☆☆☆ 2 of 5 |
| Quality: long-stay / short-stay | 2 / 2 of 5 |
Staffing
| Total nurse staffing | 4.70345 hours per resident per day |
|---|---|
| Registered nurses | 0.96318 hours per resident per day |
| Weekend total | 4.04776 hours per resident per day |
| Nursing staff turnover | 73.3% (registered nurses 72.2%) |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2026-02-09 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
H Actual harm that is not immediate jeopardy; pattern | Deficient, Provider has date of correction 2026-04-27 |
| 2026-02-09 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2026-04-27 |
| 2026-02-09 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Quality of Life and Care Deficiencies · tag F0744 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2026-03-31 |
| 2026-02-09 | Not hire anyone with a finding of abuse, neglect, exploitation, or theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0606 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2026-03-31 |
| 2026-02-09 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · tag F0842 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2026-03-31 |
| 2026-02-09 | Have a plan that describes the process for conducting QAPI and QAA activities. Administration Deficiencies · tag F0865 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2026-03-31 |
| 2026-02-09 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Administration Deficiencies · tag F0868 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2026-03-31 |
| 2026-02-09 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2026-03-31 |
| 2026-02-09 | Implement a program that monitors antibiotic use. Infection Control Deficiencies · tag F0881 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2026-03-31 |
| 2026-02-09 | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Infection Control Deficiencies · tag F0882 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2026-03-31 |
| 2026-02-09 | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Administration Deficiencies · tag F0944 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2026-03-31 |
| 2026-02-09 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · tag F0657 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-03-31 |
| 2026-02-09 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-03-31 |
| 2026-02-09 complaint survey |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · tag F0755 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-03-31 |
| 2026-02-09 | 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. Pharmacy Service Deficiencies · tag F0761 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-03-31 |
| 2026-02-09 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Resident Rights Deficiencies · tag F0561 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-03-31 |
| 2026-02-09 | 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. Resident Rights Deficiencies · tag F0585 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-03-31 |
| 2026-02-09 complaint survey |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-03-31 |
| 2026-02-09 complaint survey |
Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-03-31 |
| 2026-02-09 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Resident Rights Deficiencies · tag F0628 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-03-31 |
| 2026-02-09 | 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. Quality of Life and Care Deficiencies · tag F0688 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-03-31 |
| 2026-02-09 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · tag F0690 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-03-31 |
| 2026-02-09 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · tag F0695 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-03-31 |
| 2026-02-09 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · tag F0756 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-03-31 |
| 2026-02-09 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · tag F0757 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-03-31 |
| 2026-02-09 complaint survey |
Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · tag F0759 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-03-31 |
| 2026-02-09 complaint survey |
Post nurse staffing information every day. Nursing and Physician Services Deficiencies · tag F0732 |
C No actual harm, with potential for minimal harm; widespread | Deficient, Provider has date of correction 2026-03-31 |
| 2025-07-21 complaint survey |
Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-08-08 |
| 2025-07-21 complaint survey |
Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · tag F0692 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-08-08 |
| 2025-05-30 complaint survey |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-06-19 |
| 2025-02-11 complaint survey |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · tag F0842 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-03-07 |
| 2024-12-26 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-01-21 |
| 2024-12-26 complaint survey |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · tag F0755 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-01-21 |
| 2024-09-23 complaint survey |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2024-10-23 |
| 2024-09-23 complaint survey |
Keep all essential equipment working safely. Environmental Deficiencies · tag F0908 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-10-23 |
| 2024-09-23 complaint survey |
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. Resident Rights Deficiencies · tag F0563 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-11-01 |
| 2024-09-23 | 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. Resident Rights Deficiencies · tag F0578 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-11-01 |
| 2024-09-23 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-10-23 |
| 2024-09-23 complaint survey |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-11-01 |
| 2024-09-23 complaint survey |
Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-11-01 |
| 2024-09-23 complaint survey |
Provide medically-related social services to help each resident achieve the highest possible quality of life. Quality of Life and Care Deficiencies · tag F0745 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-11-01 |
| 2024-04-17 complaint survey |
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. Resident Rights Deficiencies · tag F0585 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-05-14 |
| 2024-04-17 complaint survey |
Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · tag F0677 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-05-14 |
| 2024-04-17 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-05-14 |
| 2024-01-23 complaint survey |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-03-07 |
| 2024-01-23 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-03-07 |
| 2023-10-05 complaint survey |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · tag F0755 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-11-09 |
| 2023-06-22 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · tag F0641 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-08-07 |
| 2023-06-22 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · tag F0755 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-07-26 |
| 2023-06-22 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies · tag F0867 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-07-20 |
| 2023-06-22 | Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Resident Assessment and Care Planning Deficiencies · tag F0661 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-07-26 |
| 2023-06-22 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-07-20 |
| 2023-06-22 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-07-26 |
| 2023-06-22 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · tag F0692 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-07-26 |
| 2023-06-22 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · tag F0756 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-07-20 |
| 2023-06-22 | 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. Pharmacy Service Deficiencies · tag F0758 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-07-26 |
| 2023-06-22 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · tag F0732 |
C No actual harm, with potential for minimal harm; widespread | Deficient, Provider has date of correction 2023-07-15 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2024-09-23 | Payment denial for 19 days from 2024-10-26 | — |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Ascension Health Senior Care Organization | 5% or greater direct ownership interest | 100% | 2014-07-01 |
| Ascension Health Senior Care Organization | adp of the snf | — | 2015-07-14 |
| Health Dimensions Consulting Inc. Organization | adp of the snf | — | 2019-08-02 |
| House Healthcare Solutions LLC Organization | adp of the snf | — | 2025-06-10 |
| Intelycare Inc. Organization | adp of the snf | — | 2022-02-08 |
| Medical Solutions LLC Organization | adp of the snf | — | 2017-06-14 |
| Metis Ltc LLC Organization | adp of the snf | — | 2024-09-02 |
| Personnel Specialists LLC Organization | adp of the snf | — | 2025-04-10 |
| Prolink Healthcare LLC Organization | adp of the snf | — | 2023-04-26 |
| Ajayi, Olusola Individual | adp of the snf | — | 2025-05-19 |
| Musgrave, Lisa Individual | adp of the snf | — | 2024-01-01 |
| Shadbolt, Erin Individual | adp of the snf | — | 2024-01-01 |
| Sidhu, Sarfraz Individual | adp of the snf | — | 2025-05-01 |
| Smoot, Kenneth Individual | adp of the snf | — | 2024-01-01 |
| Musgrave, Lisa Individual | corporate director | — | 2024-01-01 |
| Shadbolt, Erin Individual | corporate director | — | 2024-01-01 |
| Smoot, Kenneth Individual | corporate director | — | 2024-01-01 |
| Shadbolt, Erin Individual | corporate officer | — | 2022-10-17 |
| Ajayi, Olusola Individual | operational/managerial control | — | 2025-05-19 |
| Sidhu, Sarfraz Individual | operational/managerial control | — | 2025-05-01 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Ascension Living - Lakeshore At Siena.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Racine County.