Inspection visit
Fire Safety inspection
Citations
16 citations recorded*CMS
This is a Fire Safety survey. CMS cites these findings under the Life Safety Code and Emergency Preparedness rules, a separate set from the health (F-tag) deficiencies. The codes and grading differ, so these do not link to the health violation pages.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0711GeneralS&S Fpotential for harm
Provide a written emergency evacuation plan.
- 0712GeneralS&S Fpotential for harm
Have simulated fire drills held at unexpected times.
- 0761GeneralS&S Fpotential for harm
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- 0920GeneralS&S Dpotential for harm
Ensure proper usage of power strips and extension cords.
- 0004GeneralS&S Fpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
- 0132GeneralS&S Epotential for harm
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
- 0211GeneralS&S Dpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0222GeneralS&S Epotential for harm
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.
- 0291GeneralS&S Cno actual harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0341GeneralS&S Fpotential for harm
Install a fire alarm system that can be heard throughout the facility.
- 0354GeneralS&S Fpotential for harm
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
- 0374GeneralS&S Epotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- 0511GeneralS&S Dpotential for harm
Have properly installed electrical wiring and gas equipment.
- 0521GeneralS&S Fpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
FAQ · About this visit
Common questions about this visit
What happened during the September 23, 2024 survey of Ascension Living - Lakeshore at Siena?
This was a inspection survey of Ascension Living - Lakeshore at Siena on September 23, 2024. The surveyor cited 16 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Ascension Living - Lakeshore at Siena on September 23, 2024?
Yes, 16 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide a written emergency evacuation plan."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.