Ascension Living - Lakeshore at Siena

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

Rule F0686. H: actual harm. Correction date, as CMS recorded it: Apr 27, 2026.

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Rule F0744. G: actual harm. Correction date, as CMS recorded it: Mar 31, 2026.

Honor the resident’s right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Rule F0561. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2026.

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.

Rule F0585. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2026.

Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

Rule F0606. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2026.

Provide the required documentation or notification related to the resident’s needs, appeal rights, or bed-hold policies.

Rule F0628. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2026.

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Rule F0657. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2026.

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.

Rule F0688. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2026.

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Rule F0690. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2026.

Provide safe and appropriate respiratory care for a resident when needed.

Rule F0695. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2026.

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Rule F0756. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2026.

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Rule F0757. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2026.

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.

Rule F0761. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2026.

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

Rule F0842. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2026.

Have a plan that describes the process for conducting QAPI and QAA activities.

Rule F0865. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2026.

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Rule F0868. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2026.

Provide and implement an infection prevention and control program.

Rule F0880. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2026.

Implement a program that monitors antibiotic use.

Rule F0881. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2026.

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Rule F0882. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2026.

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Rule F0944. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2026.

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

Rule F0689. G: actual harm. From a complaint. Correction date, as CMS recorded it: Apr 27, 2026.

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

Rule F0609. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Mar 31, 2026.

Respond appropriately to all alleged violations.

Rule F0610. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Mar 31, 2026.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Rule F0684. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Mar 31, 2026.

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

Rule F0755. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Mar 31, 2026.

Ensure medication error rates are not 5 percent or greater.

Rule F0759. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Mar 31, 2026.

Post nurse staffing information every day.

Rule F0732. C: no actual harm, potential for minimal harm. From a complaint. Correction date, as CMS recorded it: Mar 31, 2026.

Respond appropriately to all alleged violations.

Rule F0610. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Aug 8, 2025.

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

Rule F0692. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Aug 8, 2025.

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

Rule F0609. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jun 19, 2025.

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

Rule F0842. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Mar 7, 2025.

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

Rule F0689. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 21, 2025.

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

Rule F0755. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 21, 2025.

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.

Rule F0578. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Nov 1, 2024.

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

Rule F0686. G: actual harm. From a complaint. Correction date, as CMS recorded it: Oct 23, 2024.

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

Rule F0563. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Nov 1, 2024.

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

Rule F0600. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 23, 2024.

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

Rule F0609. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Nov 1, 2024.

Respond appropriately to all alleged violations.

Rule F0610. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Nov 1, 2024.

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Rule F0745. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Nov 1, 2024.

Keep all essential equipment working safely.

Rule F0908. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 23, 2024.

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.

Rule F0585. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 14, 2024.

Provide care and assistance to perform activities of daily living for any resident who is unable.

Rule F0677. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 14, 2024.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Rule F0684. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 14, 2024.

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

Rule F0686. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Mar 7, 2024.

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

Rule F0689. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Mar 7, 2024.