Geneva Lake Manor: PASARR Screening Failure - WI
The screening, called a Pre-admission Screening and Resident Review, or PASARR Level I, is supposed to happen at admission. It determines whether a resident may need specialized psychiatric services beyond what a nursing home can provide. For the resident identified in the inspection report as R37, it didn't happen. Not at admission. Not for weeks afterward.
R37 carried a documented history of chronic bipolar disorder, depression, anxiety, and post-traumatic stress disorder. Hospital records from December 20, 2024 noted all four diagnoses. The facility admitted R37 with full knowledge of that history.
The person responsible for completing PASARR screenings at Geneva Lake Manor was the facility's Medicaid Pending Manager, identified in the report as MPM-C. On February 27, 2025, at 1:39 in the afternoon, a surveyor sat down with MPM-C and asked whether R37's Level I PASARR had been completed.
MPM-C said she had completed it that day. That morning. February 27th.
The surveyor noted R37 had been admitted weeks earlier.
MPM-C explained that she works across six other facilities and sometimes doesn't catch everything.
That was the explanation. Seven facilities, things get missed.
What MPM-C also told the surveyor is that the Level I screening had now been submitted, but the follow-up Level II PASARR, which her own account indicated was required, had not been completed. It had been requested. Not completed. Requested.
Geneva Lake Manor's written admission policy, though it carries no date, is unambiguous. It states the facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine whether the individual meets criteria for a mental disorder, intellectual disability, or related condition. The policy does not carve out exceptions for facilities that share staff with six other buildings.
At 3:02 that same afternoon, the surveyor informed the Nursing Home Administrator, identified as NHA-A, the Assistant Nursing Home Administrator, identified as ANHA-D, and the Director of Nursing, identified as DON-B, of the problem. All three acknowledged the concern. The inspection report records no further response from any of them.
The PASARR process exists specifically for residents like R37. When someone with a serious mental health diagnosis moves into a nursing facility, the screening is designed to determine whether that setting can actually meet their needs, or whether they require a level of psychiatric support the facility isn't equipped to provide. Skipping it doesn't just create a paperwork gap. It means nobody formally asked that question.
R37 had been living at Geneva Lake Manor, with diagnoses of bipolar disorder, depression, anxiety, and PTSD, for weeks before anyone ran the assessment that was supposed to precede or accompany admission. Whether R37's needs were being met during that time, whether additional services were warranted, whether a Level II review will change anything about their care, the inspection report does not say.
What it says is that MPM-C completed the screening the day a surveyor asked why it hadn't been done. And that the follow-up assessment, the one that determines whether specialized psychiatric services are needed, was still pending when inspectors left.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Geneva Lake Manor from 2025-03-17 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 5, 2026 · Our methodology
Geneva Lake Manor in Lake Geneva, WI was cited for violations during a health inspection on March 17, 2025.
The screening, called a Pre-admission Screening and Resident Review, or PASARR Level I, is supposed to happen at admission.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.