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Deficiency Records for Ascension Living - Lakeshore at Siena

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.

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?
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
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2024-04-17 2024-05-14 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2024-04-17 2024-05-14 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2024-01-23 2024-03-07 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 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 N
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

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