5643 Erie Street, Racine, WI 53402 · Racine County · (262) 898-9100
60 certified beds, about 53 residents a day · Non profit - Church related · Medicare and Medicaid since 1992
CMS Care Compare ratings, data as of September 1, 2026 · CCN 525495 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on February 9, 2026, inspectors cited 27 health deficiencies (the Wisconsin average is 9.5, the national average 9.2).
Of 57 health citations since June 2023, 4 were rated as actual harm or immediate jeopardy to residents.
CMS lists 1 fine totaling $218,735 in the last three years; the largest was $218,735, and the latest is dated February 9, 2026.
Nurses and nurse aides worked 4.70 hours per resident per day, against 4.21 across Wisconsin and 3.86 nationally. Registered nurses accounted for 0.96 of those hours.
73.3% of nursing staff left within the year CMS measured (Wisconsin average 46.9%).
CMS links it to Ascension Living, an affiliated group of 12 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 57 health citations on file.
Inspectors wroteBased 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. [...]
Inspectors wroteBased 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. The fall was not thoroughly assessed, and no revisions were made to R58's falls care plan to prevent future falls. [...]
Inspectors wroteBased 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. R41's behaviors and interventions were not reassessed and R41 did not receive a consult for psych services.
Inspectors wroteBased on record review and interview, the facility did not ensure it did not employ individuals who were found guilty of abuse, neglect, exploitation or mistreatment by failing to conduct a background information disclosure (BID) every four years for 1 (Director of Facilities Management-W) of 13 facility staff reviewed. This has the potential to affect all 53 residents residing at the facility.
Inspectors wroteBased on observation, interview, and record review, the facility did not ensure resident medical records were safeguarded against loss, destruction, or authorized use. Resident medical records were observed in cardboard boxes sitting directly on the floor and uncovered, and resident medical records were observed in a storage room which also contained items for the maintenance department. This has the potential to affect all 53 residents residing in the facility.
Inspectors wroteBased on interview and record review, the facility's Quality Assurance Committee did not make a good faith effort to identify and correct systemic deficiencies prior to the survey. This deficient practice has the potential to affect all 53 residents at the facility. During a recertification, complaint, and extended survey conducted on 1/20/2026-2/9/2026, it was determined 27 deficiencies existed. Three of the 27 deficiencies have been identified as actual harm, including treatment and services to prevent and heal pressure ulcers at F686, freedom from accident hazards at F689, and treatment and services for dementia at F744. The scope and severity at tags F606 and F686 are considered substandard quality of care. [...]
Inspectors wroteBased on record review and interview, the facility did not maintain a quality assessment and assurance committee consisting of the required members to identify issues through the committee. This deficient practice has the potential to affect all 53 residents currently in the facility. The Director of Nursing (DON) did not attend Quality Assurance Performance Improvement (QAPI) meetings on 4 of 10 months reviewed.
Inspectors wroteBased on record review and interview, the facility did not implement an effective infection control program in the facility. This has the potential to affect all 53 residents in the facility.* The facility did not maintain documentation of an on-going infection surveillance in the facility. * The facility did not have documentation of preventative action, and investigation, into 2 covid outbreaks.* The facility did not implement appropriate isolation and enhanced barrier precautions effectively for R11, R66, R67 and R4. Cross Reference F756, F757, F881 and F882.
Inspectors wroteBased on record review and interview, the facility did not establish an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. The facility did not have documentation of antibiotics being administered in the facility including indications for use, duration, isolation, organism, administering for definition of infection criteria. This has the potential to affect all 53 residents in the facility.
Inspectors wroteBased on record review and interview, the facility did not have a designated, and functional, Infection Preventionist (IP) implementing the facility Infection Control policy and procedures. This deficient practice has the potential to affect all 53 residents currently in the facility.* The facility had changes in the IP role and the Nursing Home Administrator (NHA)-A and Director of Nurses (DON)-B are overseeing the program. There is a Quality Director (QA)- L who is still in training for the role.
Inspectors wroteBased on interview and record review, the facility did not ensure 2 of 5 direct care staff chosen at random received Quality Assurance and Performance Improvement (QAPI) training with the potential to affect all 32 residents in the facility.* Certified nursing assistant (CNA)-DD and CNA-EE did not receive QAPI training annually.
Inspectors wroteBased on interview and record review, the facility did not ensure 6 (R6, R1, R49, R5, R58, and R38) of 14 residents care plans reviewed were revised accordingly. *R6 had a stage 3 pressure injury to the sacrum that healed and re-opened twice. R6's pressure injury care plan was not revised with interventions to prevent R6's sacral injury from reopening or prevent further decline. R6 developed stage 2 to the left ischium and a stage 2 pressure injury that declined to stage 3 to the right ischium. R6's pressure injuries to the left and right ischium were not addressed on the care plan, along with interventions to prevent further decline. R6's refusal to interventions to offload heels and be repositioned were not addressed in R6's care plan. *R1 developed a Deep Tissue Injury (DTI) on their left buttock on 1/13/26. [...]
Inspectors wroteBased on observation, interview, and record review, the facility did not comprehensively assess residents to ensure residents receive treatment and care in accordance with professional standards of practice for 5 (R2, R66, R62, R38, and R5) of 14 sampled residents. *R2 developed maceration in the gluteal fold on 1/20/2026 that was not comprehensively assessed and Certified Nursing Assistant (CNA)-H stated CNA-H had been applying an antifungal powder; R2 did not have an order for antifungal powder. *R66 was admitted to the facility with cellulitis to the right lower leg. The right lower leg cellulitis was not comprehensively assessed and documented. Treatment orders were entered into the Treatment Administration Record without documenting where the treatment was to be applied. *R62 had an unwitnessed fall on 1/26/2026. [...]
Inspectors wrote6) R61 was admitted to the facility on [DATE] with diagnoses which include generalized anxiety disorder. R61 an activated Healthcare Power of Attorney (HCPOA). R61's admission Minimum Data Set (MDS), dated [DATE], indicates R61 has a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment, has anxiety, depression, receives antianxiety and antidepressant medication. Surveyor reviewed R61's Facility provided document, titled Medication Record for 09/2025. Surveyor noted R61 has an order for Hydroxyzine 10 milligrams (mgs) (Atrax, can be used to treat anxiety, tension) by mouth, 3 times per day (8AM, 12PM, 4PM) with a start date of 9/16/2025 and end date 9/25/2025. The following dates and times are noted where R61 received the scheduled medication outside of the scheduled time frames, including the 1 hour before or 1 hour after standard of practice: [...]
Inspectors wroteBased on observation, interview, and record review, the facility did not store medications in the proper temperature potentially affecting 25 of 53 residents. The medication refrigerators in one of two medication storage rooms were consistently colder than the recommended range for temperature.
Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R17) of 14 residents reviewed received the right to self-determination through support of resident choice. The facility failed to accommodate R17's preference for a morning shower.
Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R7) of 1 resident reviewed for grievances received corrective actions taken by the facility. R7 filed a grievance with the facility on 2/18/25, and there is no evidence that corrective action was taken by the facility to resolve the grievance.
Inspectors wroteBased on interview and record review, the facility did not ensure 2 (R4, R41) of 3 residents with allegations of resident-to-resident abuse and injuries of unknown origin were reported to the State Agency.*On 10/1/2025, a resident-to-resident incident occurred. R41 entered R4's room, grabbed R4's forearm causing R4 to scream in fear and feel pain in R4's forearm.*On 11/8/2025, R41 was discovered to have an injury of unknown origin which was an abrasion to the head.
Inspectors wroteBased on record review and interviews, the facility did not ensure a thorough investigation was completed for 2 (R4 and R41) of 3 Residents reviewed for allegations of abuse/neglect and injury of unknown origin investigations.*On 10/1/2025, a resident-to-resident incident occurred. R41 entered R4's room, grabbed R4's forearm causing R4 to scream in fear and feel pain in R4's forearm.*On 11/8/2025, R41 was discovered to have an injury of unknown origin which was an abrasion to the head. The investigation was not started until 11/11/2025, 3 days later, and was not thorough. The investigation did not include statements from staff who first identified the injury and does not include determination of possible cause.
Inspectors wroteBased on interview and record review, the facility did not ensure 2 (R58 and R7) of 2 residents reviewed for transfer and bed hold notices were notified of the reason for transfer to the hospital and bed hold policy in writing to the resident and/ or their representative and the rate to reserve the resident's bed was not provided to the resident and/ or their representative. A bed hold rate is not provided to residents on Medicaid. *R58 was transferred and admitted to the hospital on [DATE] for further evaluation. A transfer notice and bed hold form were not provided in writing, and a bed hold rate was not provided to R58 and/or R58's representative. *R7 was transferred and admitted to the hospital on [DATE] and 11/11/2025 for further evaluation. A transfer notice and bed hold form were not provided in writing, and a bed hold rate was not provided to R7 and/or R7's representative.
Inspectors wroteBased on observation, record review and interview, the facility did ensure a resident was provided the appropriate care and services with a mobility device. This was observed with 1(R5) of 3 residents reviewed with mobility devices. R5 was observed with a left palm guard device. There was not a documented assessment for use and care of this device.
Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 1 (R67) of 4 residents reviewed received appropriate treatment and services related to catheter care. R67 was admitted to the facility on [DATE] with an indwelling catheter. R67 did not have a baseline catheter care plan initiated and observations were made of R67's catheter not having a privacy cover on it per R67's preference.
Inspectors wroteBased on observation, record review and interview, the facility did not ensure a resident received appropriate oxygen services and administration. This was observed with 1 (R1) of 2 residents reviewed with oxygen services.* R1 was observed receiving oxygen per nasal cannula during the survey. R1 did not have a physician order for oxygen administration, nor was it documented as being administered.
Inspectors wroteBased on interview and record review, the facility did not act upon the pharmacy medication review reports when received for 2 (R1 and R6) of 6 residents reviewed. *R1'S Medication Regimen Review Recommendations, dated 1/5/26, indicates they are receiving the antibiotic levofloxacin without a stop date. R1's Primary Care Physician signed the recommendation on 1/22/26 and referred to the prescribing Physician. This recommendation on 1/5/26 was not acted upon promptly. *R6's monthly pharmacy reviews noted a recommendation reported on 8/4/2025, 10/6/2025 and 10/7/2025. There was no documentation the attending physician acted upon the recommendations from the pharmacist.
Inspectors wroteBased on interview and record review the facility did not ensure 2 (R1 and R67) of 7 residents drug regimen were free of unnecessary drugs. *R1's facility admission physician orders on 11/25/25 prescribe the following: Acyclovir 800 mg BID for pneumonia with no stop date, Levofloxacin 500 mg every day for pneumonia with no stop date and Bactrim-DS 800-160 mg 3 x week for Urinary Tract Infection (UTI) with no stop date. The diagnosis of these medications is listed on the Medication Administration Records for December 2025 and January 2026. The Physician Assistant (PA) Visit Note on 11/25/25 documents the Levofloxacin end of therapy is 11/25/25, and the Acyclovir and Bactrim-DS are prophylaxis for Mantle Cell Lymphoma which did not transfer to R1's MAR. [...]
Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the medication error rate was not 5 percent or greater. 2 (R49 and R21) of 3 residents observed during medication pass were affected. The medication error rate was 30 percent, 9 errors out of 30 opportunities.
Inspectors wroteBased on interview and record review, the facility did not ensure staff postings were displayed daily or were accurate to the actual staffing of the facility. Review of staffing schedules and required staff postings from 12/1/2025 -1/20/2026 revealed 7 of 51 daily staff postings were unable to be located. In addition, 2 of 44 days of postings available for review had discrepancies between staffing schedules and staff postings. This resulted in inaccuracies with the total number of licensed staff directly responsible for resident care on night (NOC) shift. This deficient practice has potential to affect 53 out of 53 residents.
Inspectors wroteBased on record review and interviews, the facility did not ensure a thorough investigation was completed for allegations of abuse/neglect for 1 (R7) of 2 Residents reviewed for alleged abuse. *The Facility did not ensure a thorough investigation was completed related to the allegation of neglect of R7 which was reported by Adult Protective Services on 6/24/25.
Inspectors wroteBased on interview, and record review, the facility did not ensure residents received adequate fluid intake for 1 (R1) of 1 Residents reviewed for nutrition. R1was transferred from the facility to the hospital on [DATE] due to weakness, encephalopathy (a disturbance of brain function causing confusion, and abnormal lab values). The facility did not ensure R1 received adequate fluid intake to maintain acceptable parameters of hydration as evidenced by failing to total and assess daily fluid intake, accurately assess and complete on-going assessments for signs and symptoms of dehydration when R1 was assessed to be at risk for dehydration and had a history of poor oral intakes.
Inspectors wroteBased on interview, document review, and review of facility policy, the facility failed to ensure that there was evidence that an initial report of an abuse allegation was submitted to the State Survey Agency (SA) within two hours for one of two residents (Resident (R) 5) reviewed for abuse from a total sample of 13 residents. This failure had the potential to delay corrective measures and appropriate response to abuse allegations ensuring the safety of the residents.
Inspectors wroteBased on interview and record review the facility did not ensure 1 (R2) of 3 residents reviewed had a complete and accurate medical record. R2 had a diabetic wound ulcer and was being followed by Wound MD-C for four weeks. The facility changed their contract with Wound MD-C and obtained a new contract with Wound MD-D. The facility did not obtain Wound MD-C documentation of R2 wounds assessments. Surveyor asked to review R2's wound assessments from Wound MD-C and Nursing Home Administrator (NHA)-A stated the facility has no access to those records because they ended the contract with Wound MD-C.
Inspectors wroteBased on interview and record review, the facility did not ensure that 2 (R1, R2) of 3 residents reviewed were kept safe from accidents or hazards. *R1 sustained 3 falls while residing at the facility. The facility did not ensure that fall risk assessments were completed for each fall. The facility did not implement appropriate fall interventions for R1. *R2 was hit in the lip during a hoyer lift transfer on 11/25/24. The facility did not ensure staff reported the incident so that the facility was able to evaluate the circumstances on how the accident occurred and how to prevent future similar accidents from occurring.
Inspectors wroteBased on interview and record review, the facility did not ensure medication administration records were complete and accurate for 1 (R2) of 4 residents reviewed for medication administration. * R2's Medication Administration Record (MAR) indicated R2 was given R2's prescribed narcotic pain medication twice in the month of November 2024. The Facility's controlled drug log indicated R2's prescribed narcotic medication was signed out six times in the month of November 2024.
Inspectors wroteBased 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. On 10/3/2023, R307's left heel is assessed to have declined to an unstageable pressure injury.
Inspectors wroteBased upon observation and interview, the Facility did not ensure Facility equipment was maintained in proper working order for 2 of 3 dishwashing machines located in the on unit kitchens. The machines were leaking water onto the floor. 1 of 3 dishwashers did not display temperatures. This deficient practice has the potential to affect 24 of 24 residents total on the 2 units. *Surveyor observed 2 of 3 dishwashing machines in the on the unit kitchens, to be leaking water onto the floor, causing a potential hazard. *Surveyor observed 1 of 3 dishwashing machines in the on unit kitchen, did not have a temperature display to properly identify the dishwasher is reaching required water temperature.
Inspectors wroteBased on interviews and record review, the facility did not ensure the right of a Resident to receive visitors and at the time of their choosing for 1 (R36) of 1 Resident reviewed for visitation rights. The facility restricted a family member immediate access to R36 without developing any strategies to continue safe and enjoyable visits for R36.
Inspectors wroteBased on interview and record review the facility did not ensure advanced directives were in the resident's medical record for 2 (R6, R19) of 13 residents reviewed. R6 did not have a Do Not Resuscitate consent form placed in R6's medical record. The facility was unable to locate the signed form. R19 did not have a Do Not Resuscitate consent form place in R19's medical record. The facility was able to locate the signed form.
Inspectors wroteBased on interview and record review the facility did not ensure residents were free from abuse/neglect for 1 (R19) of 4 residents reviewed for abuse/neglect. R19 was transferred using a Hoyer lift and assist of 1 staff member instead of 2 staff members per R19's care plan resulting in a bruise to R19's right forearm.
Inspectors wroteBased on interview and record review the facility did not report 3 allegations of abuse/neglect for 1 Resident (R36) of 4 residents reviewed for allegations of abuse, neglect, misappropriation, or injury of unknown origin allegations, immediately to the Nursing Home Administrator or to the State Agency within the required timeframe. *An allegation of verbal abuse was observed between R36's family and R36 which was alleged to have occurred on 08/11/2024. This incident was not reported to Nursing Home Administrator (NHA)-A until 08/15/2024. NHA-A reported the allegation of verbal abuse on 08/16/2024 at 03:06 PM to the State Agency. *An allegation of physical abuse was alleged to have occurred between R36's family and R36 on 08/10/2024 and 08/11/2024. It was not reported to NHA-A until 08/17/2024. [...]
Inspectors wroteBased on record review and interviews, the facility did not ensure a thorough investigation was completed for 3 allegations of abuse/neglect for 1 (R36) of 4 residents reviewed for alleged abuse investigations. *The Facility did not ensure a thorough investigation was completed related to the allegation of verbal abuse of R36 by R36's daughter which was to have occurred on August 11, 2024. *The Facility did not ensure a thorough investigation was completed related to the allegation of physical abuse of R36 by R36's daughter which were identified during the investigation of the August 11, 2024, alleged verbal abuse. *On 6/2/24, Registered Nurse-G documented R36's daughter expressed a concern R36 was left up for 40 hours continuously and the Facility did not investigate the allegation of neglect.
Inspectors wroteBased on interview and record review the facility did not ensure that 1 (R36) of 13 Residents reviewed were provided medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being. * R36's family member was denied regular visitation and the facility implemented appointment only supervised visitation with R36's family member. An assessment and monitoring of how the decision was affecting R36 was not completed. No meetings with R36's Family member and Power of Attorney for Healthcare (HCPOA) were conducted to establish how visits with R36's family would continue in the future.
Inspectors wroteBased on interview and record review, the facility did not make a prompt effort to resolve grievances for 4 (R4, R5, R6, & R7) of 4 residents reviewed for grievances. *On 11/13/23, R4 voiced concerns to the facility that R4 was not dressed or gotten out of bed until 2nd shift and did not receive a shower. The facility did not follow up with R4 to ensure that after speaking with staff there were any further concerns regarding not getting dressed, getting out of bed, or being showered. R4's grievance does not include the date the written decison was issued. * On 11/13/23, R5 voiced a concern to the facility that R5 was not dressed until 2nd shift. R5's grievance does not include a summary of findings or a conclusion. After interviewing staff, the facility did not follow up with R5 to see if there were any further concerns regarding not getting dressed. [...]
Inspectors wroteBased on interview, and record review the facility did not ensure that 1 (R1) of 2 Residents reviewed received required assistance with their ADL's (activities daily living). R1 did not receive their weekly showers/baths consistently per their plan of care.
Inspectors wroteBased on interview and record review, the facility did not ensure that residents received needed care and services based on professional standards of practice for 1 (R2) of 2 residents reviewed. R2 was determined to be at risk for weight loss and had a physician's order for weekly weights. The facility failed to obtain weekly weights per R2's physician's order for eleven weeks. As evidenced by: The facility's weight monitoring policy dated as last reviewed on January 2023 and titled, Weight Monitoring documents under the Policy Interpretation and implementation section A. Each resident should be weighed daily for the first three days of admission, weekly for the first four weeks, and monthly thereafter. R2 was admitted to the facility on [DATE] with diagnoses of Hemiplegia following Cerebral Infarct (stroke) affecting Left side, Diabetes Mellitus Type II, Dysphagia, and Obesity. [...]
Inspectors wroteBased on observation, interview, and record review the facility did not ensure that necessary treatment and services were provided, consistent with professional standards of practice, to prevent and promote healing of pressure injuries for 1 (R3) of 3 residents reviewed for pressure injuries. R3 was admitted to the facility on [DATE], the facility did not thoroughly assess R3's wounds until 1/4/2024. Assessments included measurements but did not include a thorough assessment of the wound. R3 did not have clarification orders for R3's right buttock and left gluteal wounds on admission.
Inspectors wroteBased on observation, interview and record review the facility did not ensure 2 (R2 and R4) of 3 residents received the necessary services to prevent falls/accidents. The Facility did not thoroughly investigate R2's and R4's falls to identify a root cause and implement preventative interventions to prevent falls/accidents in the future.
Inspectors wroteBased on record review and interview, the facility failed to ensure medications were available for administration for two (Residents (R)1 and R2) upon readmission to the facility following a hospitalization out of a sample of nine residents. This had the potential to have adverse health issues for both residents.
Inspectors wrote10. R15 was admitted to the facility on [DATE] with diagnoses including, major joint replacement, infection following a procedure, weakness, unsteadiness on feet, depression and Alzheimer's disease. R15's admission Minimum Data Set Assessment (MDS) dated [DATE] documented R15 had Brief Interview for Mental Status (BIMs) of 15, indicating R15 was cognitively intact; R15 required extensive assist of 1 staff for toileting and transfers. Section D which assesses Mood documented R15 should have a mood interview conducted however the assessment is blank besides a 0 documented for trouble sleeping. Section G which assesses function status documented an 8, meaning activity did not occur during the lookback period for dressing, eating and personal hygiene and documented a 7, meaning occurred once during the look back period, for toileting. [...]
Inspectors wroteBased on observation, interview and record review the facility did not ensure 2 of 3 medication rooms were free from expired medications. Surveyor observed the 2nd floor medication room and 1st floor rehab unit medication room. Expired medications were observed in both medication rooms. This had the ability to affect total of 38 residents.
Inspectors wroteBased on interview and record review the facility's Quality Assurance Committee did not ensure a system was in place to measure the success of implemented performance improvements, and track performance to ensure that improvements are realized and sustained for the accurate completion of 11 of 14 Minimum Data Set Assessments reviewed for R10, R16, R29, R31, R17, R20, R34, R13, R2, R15, and R303. * During the recertification survey from 06/19/23 - 06/22/23, the Survey team identified concerns with inaccurate and incomplete Minimum Data Set (MDS) Assessments which were partly a result of a lack of Certified Nursing Assistant (CNA) charting. The facility had identified an issue with the lack of CNA charting and implemented improvements, but did not have a plan to measure the success of the improvements nor a plan to track the performance. (Cross Reference F641)
Inspectors wroteBased on record review and staff interviews, the facility did not always ensure that 2 out of 2 residents ( (R302, R51) who were discharged from the facility had a discharge summary that included all the pertinent information, a final summary of the resident; status at the time of discharge and a post-discharge plan of care developed with the participation of the resident and/ or representative. * R302 was discharged back into the community and the facility did not make the necessary referrals for home health so that services could be started after discharge and to assist with the transition of moving back into the community. * R51 was discharged from the facility on 5/9/23. The facility's Universal Transfer form which documents a recapulation of R51's stay was incomplete. [...]
Inspectors wroteBased on record review and staff interviews, the facility did not always ensure that they provided care and treatment, based on a comprehensive assessment, for 1 out of 4 residents (R17) reviewed who had a pressure ulcer. * R17 was readmitted to the facility, after being at the hospital for 6 days, and staff stated that R17 had a stage #3 pressure injury to the coccyx. The facility staff did not comprehensively assess the wound upon readmission and did not verify treatment orders with the physician. This wound was discovered on 4/11/23 and the facility did not provide a comprehensive assessment of the wound until 4/18/23. This is evidenced by: Policy Review; Skin Identification, Evaluation and Monitoring revised 11/2022 Purpose: The purpose of this policy is to outline a method of identification, evaluation and monitoring for alterations in skin integrity. [...]
Inspectors wroteBased on interview and record review, the facility did not ensure that each resident received needed supervision and assistance to prevent accidents for 2 (R303 and R15) 6 residents reviewed for accidents. *R303 sustained a fall and the facility did not provide an individualized fall intervention. *R15 sustained multiple falls and the facility did not thoroughly investigate the falls to determine a root cause and to establish and provide individualized person centered interventions to prevent potential further falls from occurring.
Inspectors wroteBased on observations, record review and staff interviews, the facility did not always ensure that 2 out of 2 residents ( R17, R34) who were at nutritional risk had a nutrition risk assessment received the proper assessment and care planning to help maintain acceptable parameters of nutritional status. * The facility conducted a nutritional risk assessment for R17 upon re-admission on [DATE]. The assessment indicated R17 weighed 94.2 pounds and weights were stable. The assessment indicated R17 was at risk for unintended weight loss and should be weighed weekly. R17 was noted to have a 7.7 % weight loss in 1 month (May 11- June 13, 2023). The facility did not update R17's plan of care to reflect the significant weight loss and provide additional interventions to avoid further weight loss from occurring. [...]
Inspectors wroteBased on interview and record review the facility did not ensure the physician reviewed the pharmacy recommendation timely for 1 (R15) of 5 residents reviewed for pharmacy recommendations. * R15's pharmacy recommendation from 02/11/23 recommended discontinuing R15's Tylenol PM. The same recommendation was made on 2/25/23, 3/6/23, 4/3/23, 5/1/23 and 6/5/23. R15's medical record did not contain documentation the physician was made aware of this recommendation.
Inspectors wroteBased on interview and record review the facility did not ensure 1 (R15) of 5 residents on psychotropic medications received the necessary behavior monitoring. * R15 received two anti-depressants without monitoring for effectiveness.
Inspectors wroteBased on observation, staff interviews, and record review, the facility did not ensure nurse staffing was posted daily regarding information about the number of staff directly responsible for resident care, having the potential to affect all 54 residents currently residing in the facility.
28 fire safety citations on file: 8 on February 9, 2026, 16 on September 23, 2024, 4 on June 22, 2023.
| Date | Penalty | Amount or length |
|---|---|---|
| February 9, 2026 | Fine | $218,735 |
| February 9, 2026 | Payment Denial | 47 days from March 11, 2026 |
| September 23, 2024 | Payment Denial | 19 days from October 26, 2024 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Wisconsin | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 4.70 | 4.21 | 3.86 |
| Registered nurses | 0.96 | 0.99 | 0.69 |
| All nursing staff on weekends | 4.05 | 3.77 | 3.42 |
| Nurse aides | 2.49 | ||
| Licensed practical nurses | 1.25 | ||
| Nursing staff turnover (share who left in a year) | 73.3% | 46.9% | 45.8% |
| Registered nurse turnover | 72.2% | 39.7% | 42.9% |
| Administrators who left | not reported |
CMS expects 4.26 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.97 on weekdays and 4.05 on weekends, 19% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 41.8% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.27 in April to June 2025 to 4.70 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 4.70 | 0.96 | 4.97 | 4.05 | 41.8% | 0 of 90 | 53 |
| Oct to Dec 2025 | 4.93 | 0.87 | 5.06 | 4.61 | 41.8% | 0 of 92 | 49 |
| Jul to Sep 2025 | 4.17 | 0.88 | 4.26 | 3.94 | 34.6% | 0 of 92 | 49 |
| Apr to Jun 2025 | 4.27 | 0.99 | 4.44 | 3.86 | 24.0% | 0 of 91 | 53 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Wisconsin, Jan to Mar 2026 | 4.19 | 0.95 | 4.36 | 3.74 | 8.8% | 0.3% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Wisconsin, all employers | |||
| CNAs (nursing assistants) | $21.70 | $19.03 to $22.75 | 28,370 |
| LPNs and LVNs | $30.65 | $28.67 to $36.06 | 7,390 |
| Registered nurses | $45.93 | $39.39 to $49.33 | 68,060 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Wisconsin | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 18.8 | 16.1 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.7 | 2.1 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.0 | 2.6 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 5.9 | 3.3 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.3 | 1.2 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 24.6 | 18.4 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 8.6 | 5.0 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 14.3 | 15.8 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 23.2 | 23.1 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 19.4 | 15.5 | 12.0 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Ascension Living - Lakeshore at Siena's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (50.1% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
50.1% this home
No different from the national rate
US median of homes 51.5% · Wisconsin: 52 better, 26 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 163 eligible stays.
10.9% this home
No different from the national rate
US median of homes 10.7% · Wisconsin: 0 better, 6 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 166 eligible stays.
6.7% this home
No different from the national rate
US median of homes 7.1% · Wisconsin: 0 better, 0 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 108 eligible stays.
58.2% this home
Median of homes: Wisconsin54.2% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 67 residents counted.
3.2% this home
Median of homes: Wisconsin0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 95 residents counted.
14.2% this home
Median of homes: Wisconsin2.2% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 95 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Wisconsin100.0% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 3 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: ASCENSION LIVING - LAKESHORE AT SIENA INC. CMS links this home to Ascension Living, a group of 12 nursing homes averaging 2.8 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Ascension Health Senior Care | 5% or greater direct ownership interest | Organization | 100% | 07/01/2014 |
| Musgrave, Lisa | Corporate director | Individual | 01/01/2024 | |
| Shadbolt, Erin | Corporate director | Individual | 01/01/2024 | |
| Smoot, Kenneth | Corporate director | Individual | 01/01/2024 | |
| Shadbolt, Erin | Corporate officer | Individual | 10/17/2022 | |
| Ajayi, Olusola | Operational/managerial control | Individual | 05/19/2025 | |
| Sidhu, Sarfraz | Operational/managerial control | Individual | 05/01/2025 | |
| Ascension Health Senior Care | Adp of the SNF | Organization | 07/14/2015 | |
| Health Dimensions Consulting Inc | Adp of the SNF | Organization | 08/02/2019 | |
| House Healthcare Solutions LLC | Adp of the SNF | Organization | 06/10/2025 | |
| Intelycare Inc | Adp of the SNF | Organization | 02/08/2022 | |
| Medical Solutions LLC | Adp of the SNF | Organization | 06/14/2017 | |
| Metis LTC LLC | Adp of the SNF | Organization | 09/02/2024 | |
| Personnel Specialists LLC | Adp of the SNF | Organization | 04/10/2025 | |
| Prolink Healthcare LLC | Adp of the SNF | Organization | 04/26/2023 | |
| Ajayi, Olusola | Adp of the SNF | Individual | 05/19/2025 | |
| Musgrave, Lisa | Adp of the SNF | Individual | 01/01/2024 | |
| Shadbolt, Erin | Adp of the SNF | Individual | 01/01/2024 | |
| Sidhu, Sarfraz | Adp of the SNF | Individual | 05/01/2025 | |
| Smoot, Kenneth | Adp of the SNF | Individual | 01/01/2024 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
These are the official offices in Wisconsin. NursingHomeClear cannot take or act on complaints.