Deficiency Records for Ascension Living - Lakeshore at Siena
Updated as of February 01, 2023
This is not the most recent data for Ascension Living - Lakeshore at Siena. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-03-13 | 2019-04-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-03-13 | 2019-04-05 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-03-13 | 2019-04-05 | 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 | 2019-03-13 | 2019-04-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-03-13 | 2019-04-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-13 | 2019-04-05 | 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 | 2019-03-13 | 2019-04-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-15 | 2019-04-05 | N |
