Ascension Living - Lakeshore at Siena

In the surveyor’s words

From the most serious findings on record at Ascension Living - Lakeshore at Siena, in the surveyor’s own words.

• Actual harm, patternF686Feb 9, 2026

  Based on observation, interview, and record review, the facility did not ensure residents received care consistent with professional standards of practice (N6, Wisconsin Nurse Practice Act) to prevent development of pressure injuries or received care to promote healing and prevent new ulcers from developing for 6 (R6, R46, R66, R35, R1, R49) of 6 residents reviewed with pressure injuries or at risk for developing pressure injuries. *R6 admitted to the facility on [DATE] with a stage 3 pressure injury to the sacrum. A comprehensive assessment of the area was not completed until 9/3/2024. R6's sacral pressure injury resolved on 10/22/2024. R6' sacral wound reopened on 4/24/2025 and 6/9/2025. No root cause was identified to determine why R6's sacral wound reopened or care plan revisions. […]

• Actual harm, isolatedF689Feb 9, 2026

  Based on observation, interview, and record review, the facility did not ensure residents received adequate supervision and assessments after falls to determine the cause of the fall to implement an intervention to prevent future falls for 5 (R58, R62, R38, R5, R41, and R46) of 9 residents reviewed for falls. *R58 had an unwitnessed fall on 8/10/2025 in the bathroom self-transferring off the toilet. The Falls Care Plan was revised to include R58 being educated to call for assistance to ambulate to the bathroom and a Call No Fall sign was placed in R58's room two days later. R58 had an unwitnessed fall out of bed on 12/27/25 and fractured the distal end of the right fibula requiring surgical repair. […]

• Actual harm, isolatedF744Feb 9, 2026

  Based on interview and record review, the facility did not provide appropriate treatment and services for 1 (R41) of 1 resident with a diagnosis of dementia, with behavioral symptoms, to allow them to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.*R41 was admitted to the facility with known behaviors related to dementia. R41 continued to have behaviors that made other residents anxious, scared and showing aggression toward staff and resulted in R41 grabbing R4 by the forearm which caused R4 to have pain. […]

• Actual harm, isolatedF686Sep 23, 2024

  Based on interview and record review, the facility did not ensure residents at risk for pressure injuries received necessary treatment and services consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 1 (R307) of 4 residents reviewed for pressure injuries. On 9/26/2023, R307 is documented to have developed a deep tissue injury to the left heel. R307's care plan was not revised until 9/29/2023. On 9/30/2023, R307 developed a suspected deep tissue injury to the right heel, there was not a comprehensive assessment completed for the right heel pressure injury until the wound doctor assessed on 10/3/2023 and R307's care plan was not revised. […]

• Actual harm, isolatedF686Mar 18, 2021

  Based on interview, observation and record review, the facility did not ensure 1 (R11) of 2 residents reviewed for pressure injuries (PI) received care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates they were unavoidable. * On 3/9/21 when the Nurse Practitioner (NP) assessed R11's Left Lower Extremity (LLE) wound and posterior ankle wound, 3 additional PI's were found on the right heel, left heel and left great toe. Even though the facility was charting daily foot checks as being completed, these wounds were not identified until 3/9/21. […]