Cycle 1
Health 2024-09-23 · Fire 2024-09-23
11 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (5 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Racine, WI
Ascension Living - Lakeshore At Siena
2-star overall rating with 2-star inspections with 11 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
5643 Erie Street, Racine, WI
(262) 898-9100
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
49
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ascension Living
Operator or chain grouping
Approved since
1992-08-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.88
Registered nurse staffing
LPN hours / resident day
0.95
Licensed practical nurse staffing
Aide hours / resident day
2.35
Nurse aide staffing
Weekend hours
3.94
Weekend nurse staffing
RN turnover
47%
Annual RN turnover
Total nurse turnover
59%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
95.7%
2.1 pts better
|
93.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.3% |
95.0%
2.3 pts better
|
95.5%
1.8 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.9% |
3.2%
4.7 pts worse
|
3.3%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
5.0%
4.2 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 11.5% |
4.9%
6.6 pts worse
|
5.4%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.9% |
16.6%
5.3 pts worse
|
19.6%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 11.0% |
16.7%
5.7 pts better
|
16.7%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 28.1% |
21.1%
7 pts worse
|
16.3%
11.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.4% |
17.3%
3.1 pts worse
|
14.9%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
2.3%
1.6 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
3.0%
2.3 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.3% |
25.5%
2.8 pts worse
|
19.8%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 7.1% |
5.5%
1.6 pts worse
|
5.1%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.6% |
86.8%
6.8 pts better
|
81.7%
11.9 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.8% |
15.0%
0.2 pts better
|
12.0%
2.8 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.3%
0.5 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.9% |
82.2%
0.7 pts better
|
79.7%
3.2 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.1% |
22.7%
5.4 pts worse
|
23.9%
4.2 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-22 · Fire 2023-06-22
16 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-03-23 · Fire 2022-03-23
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-23
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-10-23
F · Potential for more than minimal harm
2024-09-23
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-10-19
F · Potential for more than minimal harm
2024-09-23
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-11-14
F · Potential for more than minimal harm
2024-09-23
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-10-23
F · Potential for more than minimal harm
2024-09-23
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-10-29
F · Potential for more than minimal harm
2024-09-23
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-10-23
F · Potential for more than minimal harm
2024-09-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-23
F · Potential for more than minimal harm
2024-09-23
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-10-23
E · Potential for more than minimal harm
2024-09-23
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2024-10-23
E · Potential for more than minimal harm
2024-09-23
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2024-10-21
E · Potential for more than minimal harm
2024-09-23
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-10-23
E · Potential for more than minimal harm
2024-09-23
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-10-23
D · Potential for more than minimal harm
2024-09-23
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-10-23
D · Potential for more than minimal harm
2024-09-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-23
D · Potential for more than minimal harm
2024-09-23
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-21
C · Minimal harm
2024-09-23
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-10-16
E · Potential for more than minimal harm
2023-06-22
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2023-06-21
E · Potential for more than minimal harm
2023-06-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-07-11
D · Potential for more than minimal harm
2023-06-22
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-07-11
D · Potential for more than minimal harm
2023-06-22
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-06-21
F · Potential for more than minimal harm
2022-03-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-04-13
F · Potential for more than minimal harm
2022-03-23
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-04-13
F · Potential for more than minimal harm
2022-03-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-04-22
E · Potential for more than minimal harm
2022-03-23
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2022-04-13
E · Potential for more than minimal harm
2022-03-23
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-05-20
D · Potential for more than minimal harm
2022-03-23
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-03-24
D · Potential for more than minimal harm
2022-03-23
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2022-05-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-21
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-07-21
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-05-30
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-06-19
D · Potential for more than minimal harm
2025-02-11
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-03-07
D · Potential for more than minimal harm
2024-12-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-21
D · Potential for more than minimal harm
2024-12-26
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-01-21
G · Actual harm
2024-09-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-23
E · Potential for more than minimal harm
2024-09-23
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-10-23
D · Potential for more than minimal harm
2024-09-23
F563 · Resident Rights Deficiencies
Health
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-09-23
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-09-23
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-10-23
D · Potential for more than minimal harm
2024-09-23
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-09-23
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-09-23
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-04-17
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2024-05-14
D · Potential for more than minimal harm
2024-04-17
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-05-14
D · Potential for more than minimal harm
2024-04-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-14
D · Potential for more than minimal harm
2024-01-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-07
D · Potential for more than minimal harm
2024-01-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-07
E · Potential for more than minimal harm
2023-10-05
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-11-09
E · Potential for more than minimal harm
2023-06-22
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-08-07
E · Potential for more than minimal harm
2023-06-22
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-07-26
E · Potential for more than minimal harm
2023-06-22
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-06-22
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-06-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-06-22
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-06-22
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-06-22
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-06-22
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-07-26
C · Minimal harm
2023-06-22
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-07-15
D · Potential for more than minimal harm
2022-03-23
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-03-29
Penalties and ownership
What sits behind the stars
$0
2024-09-23
Payment Denial
Payment Denial · denial start 2024-10-26 · 19 days
19 day denial
Ownership
Ascension Health Senior Care
Operational/Managerial Control · Organization
Binek, Robin
Corporate Director · Individual
Breedlove, Ryan
Corporate Director · Individual
Gronefeld, Kellie
Corporate Director · Individual
Musgrave, Lisa
Operational/Managerial Control · Individual
Phillips, Michael
W-2 Managing Employee · Individual
Shadbolt, Erin
Corporate Director · Individual
Smoot, Kenneth
Corporate Director · Individual
Wisniewski, Gerald
Contracted Managing Employee · Individual
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#3
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