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Deficiency Records for Ascension Living - Lakeshore at Siena
View the most recent health deficiencies and inspection results for Ascension Living - Lakeshore at Siena. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Ascension Living - Lakeshore at Siena. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2026-02-09 | 2026-04-27 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2026-02-09 | 2026-04-27 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2026-02-09 | 2026-04-03 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2026-02-09 | 2026-03-31 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2026-02-09 | 2026-03-31 | N |
| 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. | Health | 2026-02-09 | 2026-03-31 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2026-02-09 | 2026-03-31 | N |
| Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | Health | 2026-02-09 | 2026-03-31 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2026-02-09 | 2026-03-31 | N |
| 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. | Health | 2026-02-09 | 2026-03-31 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2026-02-09 | 2026-03-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2026-02-09 | 2026-03-31 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2026-02-09 | 2026-03-31 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2026-02-09 | 2026-03-31 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2026-02-09 | 2026-03-31 | N |
| 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. | Health | 2026-02-09 | 2026-03-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2026-02-09 | 2026-03-31 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2026-02-09 | 2026-03-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2026-02-09 | 2026-03-31 | N |
| Implement a program that monitors antibiotic use. | Health | 2026-02-09 | 2026-03-31 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2026-02-09 | 2026-03-31 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2026-02-09 | 2026-03-31 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2026-02-09 | 2026-03-31 | Y |
| Respond appropriately to all alleged violations. | Health | 2026-02-09 | 2026-03-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2026-02-09 | 2026-03-31 | Y |
| Post nurse staffing information every day. | Health | 2026-02-09 | 2026-03-31 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2026-02-09 | 2026-03-31 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2026-02-09 | 2026-03-31 | Y |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2026-02-09 | 2026-03-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2026-02-09 | 2026-03-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2026-02-09 | 2026-03-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2026-02-09 | 2026-03-10 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2026-02-09 | 2026-03-10 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2026-02-09 | 2026-03-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2026-02-09 | 2026-03-10 | N |
| Respond appropriately to all alleged violations. | Health | 2025-07-21 | 2025-08-08 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2025-07-21 | 2025-08-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2025-05-30 | 2025-06-19 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-02-11 | 2025-03-07 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-12-26 | 2025-01-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-12-26 | 2025-01-21 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-09-23 | 2024-11-14 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-09-23 | 2024-11-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-09-23 | 2024-11-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-09-23 | 2024-11-01 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2024-09-23 | 2024-11-01 | Y |
| 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. | Health | 2024-09-23 | 2024-11-01 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-09-23 | 2024-10-29 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-09-23 | 2024-10-23 | N |
| Keep all essential equipment working safely. | Health | 2024-09-23 | 2024-10-23 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-09-23 | 2024-10-23 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-09-23 | 2024-10-23 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-09-23 | 2024-10-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-09-23 | 2024-10-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-09-23 | 2024-10-23 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-09-23 | 2024-10-23 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-09-23 | 2024-10-23 | 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 | 2024-09-23 | 2024-10-23 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-09-23 | 2024-10-23 | N |
| Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | Fire Safety | 2024-09-23 | 2024-10-23 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-09-23 | 2024-10-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-09-23 | 2024-10-21 | 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 | 2024-09-23 | 2024-10-21 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-09-23 | 2024-10-19 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-09-23 | 2024-10-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-04-17 | 2024-05-14 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-04-17 | 2024-05-14 | Y |
| 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. | Health | 2024-04-17 | 2024-05-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-23 | 2024-03-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-23 | 2024-03-07 | Y |
| 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 | N |
| 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 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-06-22 | 2023-07-26 | N |
| 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 | N |
| 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 | N |
| 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 |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-22 | 2023-07-20 | N |
| 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 | N |
| 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 | N |
| Post nurse staffing information every day. | Health | 2023-06-22 | 2023-07-15 | 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 | 2023-06-22 | 2023-07-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-06-22 | 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 | 2023-06-22 | 2023-06-21 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-06-22 | 2023-06-21 | N |