Nursing homeActive
Ascension Living - Lakeshore at Siena
5643 Erie Street, Racine, WI 53402262898910060 certified beds · 53 residentsNon profit - Church relatedMedicare and Medicaid
Surveys on file
10
since 2023
Deficiencies
57
● 2● 51● 4
Penalties · 3 yrs
—
1 action
Last survey
2026-02-09
Standard
CMS overall
1 / 5
stars as published by CMS
CMS overall 1/5
Health 1
Staffing 3
Quality 2
Star ratings as published by CMS · CMS’s caveats
Survey history
Source: CMS · Wisconsin Division of Quality Assurance · data as of 2026-08-01| Date | Kind | Deficiencies | Official record | Archived PDF |
|---|---|---|---|---|
| 2026-02-09 | Standard | 1233 | CMS-2567 (Care Compare) | — |
| 2025-07-21 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2025-05-30 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2025-02-11 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2024-12-26 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2024-09-23 | Standard | 071 | CMS-2567 (Care Compare) | — |
| 2024-04-17 | Complaint | 030 | CMS-2567 (Care Compare) | — |
| 2024-01-23 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2023-10-05 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2023-06-22 | Standard | 190 | CMS-2567 (Care Compare) | — |
Counts by class: paperwork · standard · harm.
Deficiencies
CMS · Wisconsin Division of Quality Assurance publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity HHarm
Care planning
Pattern; actual harm that is not immediate jeopardy.Corrected 2026-04-27Record 525495-20260209-F686
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity GHarm
Care planningFalls
Isolated; actual harm that is not immediate jeopardy.Corrected 2026-04-27Record 525495-20260209-F689
F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2026-03-31Record 525495-20260209-F744
F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-31Record 525495-20260209-F561
F585Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-31Record 525495-20260209-F585
F606Not hire anyone with a finding of abuse, neglect, exploitation, or theft.Scope/severity FStandard
Abuse & neglect
Widespread; no actual harm, potential for more than minimal harm.Corrected 2026-03-31Record 525495-20260209-F606
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-31Record 525495-20260209-F609
F610Respond appropriately to all alleged violations.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-31Record 525495-20260209-F610
F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-31Record 525495-20260209-F628
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-03-31Record 525495-20260209-F657
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-03-31Record 525495-20260209-F684
F688Provide 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.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-31Record 525495-20260209-F688
F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-31Record 525495-20260209-F690
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-31Record 525495-20260209-F695
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-03-31Record 525495-20260209-F755
F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-31Record 525495-20260209-F756
F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-31Record 525495-20260209-F757
F759Ensure medication error rates are not 5 percent or greater.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-31Record 525495-20260209-F759
F761Ensure 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.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-03-31Record 525495-20260209-F761
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity FStandard
Care planningRecords
Widespread; no actual harm, potential for more than minimal harm.Corrected 2026-03-31Record 525495-20260209-F842
F865Have a plan that describes the process for conducting QAPI and QAA activities.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2026-03-31Record 525495-20260209-F865
F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyScope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2026-03-31Record 525495-20260209-F868
F880Provide and implement an infection prevention and control program.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2026-03-31Record 525495-20260209-F880
F881Implement a program that monitors antibiotic use.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2026-03-31Record 525495-20260209-F881
F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2026-03-31Record 525495-20260209-F882
F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2026-03-31Record 525495-20260209-F944
F732Post nurse staffing information every day.Scope/severity CPaperwork
Staffing
Widespread; potential for minimal harm.Corrected 2026-03-31Record 525495-20260209-F732
F610Respond appropriately to all alleged violations.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-08-08Record 525495-20250721-F610
F692Provide enough food/fluids to maintain a resident's health.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-08-08Record 525495-20250721-F692
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-06-19Record 525495-20250530-F609
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-03-07Record 525495-20250211-F842
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-01-21Record 525495-20241226-F689
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-01-21Record 525495-20241226-F755
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2024-10-23Record 525495-20240923-F686
F563Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-01Record 525495-20240923-F563
F578Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-01Record 525495-20240923-F578
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-23Record 525495-20240923-F600
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-01Record 525495-20240923-F609
F610Respond appropriately to all alleged violations.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-01Record 525495-20240923-F610
F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-01Record 525495-20240923-F745
F908Keep all essential equipment working safely.Scope/severity EStandard
Environment
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-10-23Record 525495-20240923-F908
F585Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-14Record 525495-20240417-F585
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-14Record 525495-20240417-F677
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-14Record 525495-20240417-F684
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-03-07Record 525495-20240123-F686
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-03-07Record 525495-20240123-F689
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-11-09Record 525495-20231005-F755
F641Ensure each resident receives an accurate assessment.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-08-07Record 525495-20230622-F641
F661Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-07-26Record 525495-20230622-F661
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-07-20Record 525495-20230622-F686
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-07-26Record 525495-20230622-F689
F692Provide enough food/fluids to maintain a resident's health.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-07-26Record 525495-20230622-F692
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-07-26Record 525495-20230622-F755
F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-07-20Record 525495-20230622-F756
F758Implement 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-07-26Record 525495-20230622-F758
F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Scope/severity EStandard
Records
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-07-20Record 525495-20230622-F867
F732Post nurse staffing information every day.Scope/severity CPaperwork
Staffing
Widespread; potential for minimal harm.Corrected 2023-07-15Record 525495-20230622-F732
Penalties & enforcement
| Date | Action | Amount | Source |
|---|---|---|---|
| 2024-09-23 | Denial of payment for new admissions Payment denial for 19 days, from 2024-10-26 | — | CMS · Penalties |
Staffing
CMS Payroll-Based Journal · PBJ, as published Aug 2026 · explainerRN hours per resident day0.96
Facility
Wisconsin
National
Wisconsin 0.99 · National 0.69
Total nurse hours per resident day4.70
Facility
Wisconsin
National
Wisconsin 4.21 · National 3.86
Weekend total nurse hours4.05
Facility
Wisconsin
National
Wisconsin 3.77 · National 3.42
Total nursing staff turnover73%
Facility
Wisconsin
National
Wisconsin 47% · National 46%
Registered nurse turnover72%
Facility
Wisconsin
National
Wisconsin 40% · National 43%
Quality measures
CMS MDS quality measures · 2025Q2-2026Q1 · definitions| Measure | Facility | Wisconsin | National |
|---|---|---|---|
| Percentage of long-stay residents with pressure ulcers lower is better | 8.6% | 5.0% | 4.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury lower is better | 5.9% | 3.3% | 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication lower is better | 14.3% | 15.8% | 15.4% |
| Percentage of long-stay residents with a urinary tract infection lower is better | 0.0% | 2.7% | 1.6% |
| Percentage of long-stay residents who were physically restrained lower is better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased lower is better | 18.8% | 16.1% | 13.9% |
| Percentage of long-stay residents who lose too much weight lower is better | 10.7% | 5.1% | 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication lower is better | 23.1% | 16.9% | 19.5% |
Figures verbatim from CMS, with the state and national figures from the same release. The direction that counts as better is CMS’s own and is stated on every row.
Ownership
As reported to CMS (Provider Enrollment)| Entity | Role | Interest | Since | Registry |
|---|---|---|---|---|
| Ascension Health Senior Care Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | — | — |
| Ajayi, Olusola Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Sidhu, Sarfraz Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Ajayi, Olusola Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Ascension Health Senior Care Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Health Dimensions Consulting Inc Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| House Healthcare Solutions LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Intelycare Inc Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Medical Solutions LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Metis Ltc LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Musgrave, Lisa Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Musgrave, Lisa Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Personnel Specialists LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Prolink Healthcare LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Shadbolt, Erin Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Shadbolt, Erin Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Shadbolt, Erin Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Sidhu, Sarfraz Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Smoot, Kenneth Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Smoot, Kenneth Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
Part of a chain
Ascension Living — 12 facilities
Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.
Cost context
County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or Wisconsin.
No county cost figures on file for Racine.
Nearby nursing homes
| Facility | Distance | Last survey | Deficiencies · 3 yrs |
|---|---|---|---|
| Lincoln Park Nursing and Rehab LLC Racine | 6.5 mi | 2026-04-22 | 0495 |
| Complete Care at Ridgewood LLC Racine | 7.4 mi | 2026-04-07 | 0230 |
| Willowcrest Health Services South Milwaukee | 8.0 mi | 2025-06-05 | 2282 |
| Chi Franciscan Villa South Milwaukee | 8.1 mi | 2026-05-29 | 1508 |
| Waters Edge Health and Rehabilitation Center Kenosha | 13.1 mi | 2026-06-11 | 1588 |
Watch this facility
One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.
Sources & provenance
| Section | Agency · dataset | Retrieved |
|---|---|---|
| Facility, ratings | CMS Provider Data · Nursing Home Provider Information | 2026-08-01 |
| Surveys | CMS · Survey Summary | 2026-08-01 |
| Deficiencies | CMS · Health Deficiencies (CMS-2567 findings via Care Compare) | 2026-08-01 |
| Penalties | CMS · Penalties | 2026-08-01 |
| Staffing | CMS · Payroll-Based Journal (PBJ, as published Aug 2026) | 2026-08-01 |
| Quality measures | CMS · MDS Quality Measures | 2026-08-01 |
| Ownership | CMS · Ownership | 2026-08-01 |