All citations for Ascension Living - Lakeshore at Siena

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Ascension Living - Lakeshore at Siena

Last standard health inspection on record

February 9, 2026

Showing 1 to 25 of 30 citations

  1. Harm to a resident

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

    Isolated (one or a few residents). CMS level G.

    Health citation F-0686, Quality of Life and Care Deficiencies. Inspection of September 23, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (October 23, 2024).

  2. No harm, with potential for more than minimal harm

    Develop and maintain an Emergency Preparedness Program (EP).

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0004, Emergency Preparedness Deficiencies. Inspection of September 23, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 19, 2024).

  3. No harm, with potential for more than minimal harm

    Conduct testing and exercise requirements.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0039, Emergency Preparedness Deficiencies. Inspection of September 23, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 23, 2024).

  4. No harm, with potential for more than minimal harm

    Install a fire alarm system that can be heard throughout the facility.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0341, Smoke Deficiencies. Inspection of September 23, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 14, 2024).

  5. No harm, with potential for more than minimal harm

    Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0354, Smoke Deficiencies. Inspection of September 23, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 23, 2024).

  6. No harm, with potential for more than minimal harm

    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0521, Services Deficiencies. Inspection of September 23, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 29, 2024).

  7. No harm, with potential for more than minimal harm

    Provide a written emergency evacuation plan.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0711, Miscellaneous Deficiencies. Inspection of September 23, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 23, 2024).

  8. No harm, with potential for more than minimal harm

    Have simulated fire drills held at unexpected times.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0712, Miscellaneous Deficiencies. Inspection of September 23, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 23, 2024).

  9. No harm, with potential for more than minimal harm

    To conduct inspection, testing and maintenance of fire doors by qualified individuals.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0761, Miscellaneous Deficiencies. Inspection of September 23, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 23, 2024).

  10. No harm, with potential for more than minimal harm

    Keep all essential equipment working safely.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0908, Environmental Deficiencies. Inspection of September 23, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (October 23, 2024).

  11. No harm, with potential for more than minimal harm

    Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0132, Construction Deficiencies. Inspection of September 23, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 23, 2024).

  12. No harm, with potential for more than minimal harm

    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.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0222, Egress Deficiencies. Inspection of September 23, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 21, 2024).

  13. No harm, with potential for more than minimal harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0321, Smoke Deficiencies. Inspection of September 23, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 23, 2024).

  14. No harm, with potential for more than minimal harm

    Install smoke barrier doors that can resist smoke for at least 20 minutes.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0374, Smoke Deficiencies. Inspection of September 23, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 23, 2024).

  15. No harm, with potential for more than minimal harm

    Respond appropriately to all alleged violations.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0610, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of July 21, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (August 8, 2025).

  16. No harm, with potential for more than minimal harm

    Provide enough food/fluids to maintain a resident's health.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0692, Quality of Life and Care Deficiencies. Inspection of July 21, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (August 8, 2025).

  17. No harm, with potential for more than minimal harm

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0609, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of May 30, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (June 19, 2025).

  18. No harm, with potential for more than minimal harm

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0842, Resident Assessment and Care Planning Deficiencies. Inspection of February 11, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (March 7, 2025).

  19. No harm, with potential for more than minimal harm

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0689, Quality of Life and Care Deficiencies. Inspection of December 26, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (January 21, 2025).

  20. No harm, with potential for more than minimal harm

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0755, Pharmacy Service Deficiencies. Inspection of December 26, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (January 21, 2025).

  21. No harm, with potential for more than minimal harm

    Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0563, Resident Rights Deficiencies. Inspection of September 23, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (November 1, 2024).

  22. No harm, with potential for more than minimal harm

    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.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0578, Resident Rights Deficiencies. Inspection of September 23, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 1, 2024).

  23. No harm, with potential for more than minimal harm

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0600, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of September 23, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (October 23, 2024).

  24. No harm, with potential for more than minimal harm

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0609, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of September 23, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (November 1, 2024).

  25. No harm, with potential for more than minimal harm

    Respond appropriately to all alleged violations.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0610, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of September 23, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (November 1, 2024).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of October 1, 2026. Inspection results describe the home at the time of each inspection.