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 16 of 16 citations

  1. 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).

  2. 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).

  3. 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).

  4. 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).

  5. 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).

  6. 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).

  7. 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).

  8. 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).

  9. 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).

  10. 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).

  11. 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).

  12. 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).

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

    Keep aisles, corridors, and exits free of obstruction in case of emergency.

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

    Fire safety citation K-0211, Egress 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

    Have properly installed electrical wiring and gas equipment.

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

    Fire safety citation K-0511, Services 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

    Ensure proper usage of power strips and extension cords.

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

    Fire safety citation K-0920, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of September 23, 2024. Found during a standard inspection.

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

  16. No harm, with potential for minimal harm

    Install emergency lighting that can last at least 1 1/2 hours.

    Widespread (many residents). CMS level C.

    Fire safety citation K-0291, Egress Deficiencies. Inspection of September 23, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 16, 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.