Federal inspection record · CMS data as of October 1, 2026
Ascension Living - Lakeshore at Siena
5643 Erie Street, Racine, WI · (262) 898-9100
- Certified beds
- 60
- Residents per day
- 40
- Ownership
- Non-Profit
- Chain
- Ascension Living
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- August 18, 1992
1
How this home got 1 star
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
-
Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Wisconsin.
-
Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
-
Overall
★★★★★1 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Wisconsin homes
Ascension Living - Lakeshore at Siena carries 350 inspection points. That is fewer than 5% of Wisconsin's 321 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Wisconsin: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–11 pts
- 4★ 11–37 pts
- 3★ 37–76 pts
- 2★ 76–130.75 pts
- 1★ over 130.75 pts
Bars show every rated home in Wisconsin by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
57 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (4)
-
H
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
-
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
-
G
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
-
G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Everything else, by area of care
Quality of Life and Care14E
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide enough food/fluids to maintain a resident's health.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide enough food/fluids to maintain a resident's health.
Pharmacy Service10E
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- D
Ensure medication error rates are not 5 percent or greater.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- D
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.
Freedom from Abuse, Neglect, and Exploitation8F
- F
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Respond appropriately to all alleged violations.
- D
Respond appropriately to all alleged violations.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Respond appropriately to all alleged violations.
Resident Rights6D
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
- D
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.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
- D
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
- D
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.
- D
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.
Resident Assessment and Care Planning5F
- F
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- E
Ensure each resident receives an accurate assessment.
- D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Administration4F
- F
Have a plan that describes the process for conducting QAPI and QAA activities.
- F
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
- F
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Infection Control3F
- F
Provide and implement an infection prevention and control program.
- F
Implement a program that monitors antibiotic use.
- F
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Nursing and Physician Services2C
- C
Post nurse staffing information every day.
- C
Post nurse staffing information every day.
Environmental1E
- E
Keep all essential equipment working safely.
Inspection history
2026-02-09
27 health deficiencies · 8 fire-safety deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
2024-09-23
14 health deficiencies · 16 fire-safety deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (5 deficiencies)
2023-06-22
16 health deficiencies · 4 fire-safety deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 5 h 13 min of nursing staff time a day, 1 h 10 min of it from a registered nurse.
This home
5 h 13 min
Wisconsin average
4 h 15 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 78% of nursing staff and 78% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$218,735 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2026-02-09 | Fine | $218,735 |
| 2026-02-09 | Payment Denial · 47 day denial | $0 |
| 2024-09-23 | Payment Denial · 19 day denial | $0 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident daysAbout the same | 1.6 | 1.6 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.8 pts better | 1.4 | 2.2 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine0.1 pts better | 96.1% | 96.0% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine13.5 pts worse | 82.1% | 95.6% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury2.9 pts worse | 6.2% | 3.3% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms2.2 pts better | 3.8% | 6.0% | 13.5% |
| Percentage of long-stay residents who lose too much weight4.3 pts worse | 9.2% | 4.9% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication7.4 pts worse | 24.2% | 16.8% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication3.9 pts better | 12.0% | 15.9% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened7.6 pts worse | 24.6% | 17.0% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased6.5 pts worse | 22.3% | 15.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.9 pts better | 1.0% | 1.9% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection1.9 pts better | 0.8% | 2.7% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinenceAbout the same | 23.6% | 23.6% | 18.3% |
| Percentage of long-stay residents with pressure ulcers4.4 pts worse | 9.3% | 4.9% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine0.3 pts better | 87.2% | 86.9% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit2.8 pts worse | 18.4% | 15.6% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.9 pts better | 0.3% | 1.2% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine20.1 pts worse | 62.1% | 82.2% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission4.7 pts worse | 27.2% | 22.5% | 23.4% |
·
Who owns and runs it
20 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Ascension Health Senior Care | 5% Or Greater Direct Ownership Interest · Organization | 100% | 11 facilities |
| Ajayi, Olusola | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Ajayi, Olusola | Adp Of The SNF · Individual | 0% | 1 facilities |
| Ascension Health Senior Care | Adp Of The SNF · Organization | 0% | 11 facilities |
| Health Dimensions Consulting Inc | Adp Of The SNF · Organization | 0% | 20 facilities |
| House Healthcare Solutions LLC | Adp Of The SNF · Organization | 0% | 5 facilities |
| Intelycare Inc | Adp Of The SNF · Organization | 0% | 11 facilities |
| Medical Solutions LLC | Adp Of The SNF · Organization | 0% | 16 facilities |
| Metis Ltc LLC | Adp Of The SNF · Organization | 0% | 2 facilities |
| Musgrave, Lisa | Corporate Director · Individual | 0% | 11 facilities |
| Musgrave, Lisa | Adp Of The SNF · Individual | 0% | 11 facilities |
| Personnel Specialists LLC | Adp Of The SNF · Organization | 0% | 2 facilities |
| Prolink Healthcare LLC | Adp Of The SNF · Organization | 0% | 2 facilities |
| Shadbolt, Erin | Corporate Director · Individual | 0% | 11 facilities |
| Shadbolt, Erin | Corporate Officer · Individual | 0% | 11 facilities |
| Shadbolt, Erin | Adp Of The SNF · Individual | 0% | 11 facilities |
| Sidhu, Sarfraz | Operational/Managerial Control · Individual | 0% | 28 facilities |
| Sidhu, Sarfraz | Adp Of The SNF · Individual | 0% | 28 facilities |
| Smoot, Kenneth | Corporate Director · Individual | 0% | 10 facilities |
| Smoot, Kenneth | Adp Of The SNF · Individual | 0% | 10 facilities |
·
Fire safety
28 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke8F
- E
Provide properly protected cooking facilities.
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- D
Inspect, test, and maintain automatic sprinkler systems.
- F
Install a fire alarm system that can be heard throughout the facility.
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Miscellaneous7F
- F
Have simulated fire drills held at unexpected times.
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- D
Have restrictions on the use of highly flammable decorations.
- D
Have restrictions on the use of portable space heaters.
- F
Provide a written emergency evacuation plan.
- F
Have simulated fire drills held at unexpected times.
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Gas, Vacuum, and Electrical Systems4E
- D
Ensure proper usage of power strips and extension cords.
- D
Ensure proper usage of power strips and extension cords.
- E
Have proper medical gas storage and administration areas.
- D
Meet requirements for the use of electrical equipment.
Egress4E
- E
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.
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- C
Install emergency lighting that can last at least 1 1/2 hours.
- E
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.
Emergency Preparedness2F
- F
Conduct testing and exercise requirements.
- F
Develop and maintain an Emergency Preparedness Program (EP).
Services2F
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- D
Have properly installed electrical wiring and gas equipment.
Construction1E
- E
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
·
Other homes nearby
-
Lincoln Park Nursing and Rehab LLC
Racine, WI · Shlomo Hoffman
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 4 h 2 min
- Fines
- $182,618
-
Complete Care at Ridgewood LLC
Racine, WI · Complete Care
★★★★★- Worst citation, 3 yrs
- F
- Nursing / resident / day
- 3 h 54 min
- Fines
- $0
-
Willowcrest Health Services
South Milwaukee, WI · North Shore Healthcare
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 3 h 23 min
- Fines
- $21,285