Deficiency Records for Ascension Living - Lakeshore at Siena
Updated as of March 01, 2024
A list of the most recent deficiencies for Ascension Living - Lakeshore at Siena. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-05 | 2023-11-09 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-06-22 | 2023-08-07 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-06-22 | 2023-07-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-22 | 2023-07-26 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-06-22 | 2023-07-26 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-22 | 2023-07-26 | Y |
| 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. | Health | 2023-06-22 | 2023-07-26 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-22 | 2023-07-20 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-06-22 | 2023-07-20 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-06-22 | 2023-07-20 | Y |
| Post nurse staffing information every day. | Health | 2023-06-22 | 2023-07-15 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-06-20 | 2023-07-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-06-20 | 2023-07-11 | N |
| 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. | Fire Safety | 2023-06-20 | 2023-06-21 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-06-20 | 2023-06-21 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-03-22 | 2022-05-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-03-22 | 2022-05-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-22 | 2022-04-22 | N |
| 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. | Fire Safety | 2022-03-22 | 2022-04-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-22 | 2022-04-13 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-03-22 | 2022-04-13 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-03-23 | 2022-03-29 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-03-22 | 2022-03-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-03-18 | 2021-04-15 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-03-18 | 2021-04-08 | N |
| Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | Fire Safety | 2021-03-16 | 2021-03-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-03-16 | 2021-03-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-23 | Not Fixed | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-23 | Not Fixed | Y |
