Geneva Lake Manor

F 0607

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Level of Harm - Minimal harm or potential for actual harm

Based on interview and record review, the facility did not ensure their abuse policy and procedure was implemented for 1 of 8 employees reviewed for 4-year background checks potentially affecting a portion of

the 47 residents.Dietary Aide (DA)-P did not have an up to date background check completed within the four year time frame.Findings include:The facility policy and procedure titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program from (C)MED-PASS dated 2001 revised 4/2021 documents: 4.

Conduct employee background checks and not knowingly employ or otherwise engage any individual who has: a. been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law .On 11/6/2025, Surveyor requested from Nursing Home Administrator (NHA)-A the personnel files for eight employees to review for the required background checks.DA-P was hired on 4/27/2021. The Background Information Disclosure (BID) form, the Department of Justice (DOJ) letter, and the Interagency Border Inspection System (IBIS) form were completed on 4/27/2021. Four years had lapsed since the background check information had been submitted. On 11/6/2025 at 2:15 PM, Surveyor shared with Director of Nursing (DON)-B DA-P's background check forms were completed upon hire on 4/27/2021 and need to be completed every four years so the background check should have been completed by 4/27/2025. DON-B stated DON-B would talk to Human Resources (HR) to see if there is a more recent background check.In an interview on 11/6/2025 at 2:30 PM, HR-O stated HR-O does the background checks for all employees. HR-O stated HR-O would check and see if there was a more recent background check for DA-P and if not, HR-O would complete the background check immediately.On 11/6/2025 at 2:55 PM, NHA-A brought Surveyor the background check forms for DA-P. Surveyor noted the background check forms were dated that day, 11/6/2025, and DA-P was also listed as being an Activity Aide. NHA-A confirmed DA-P worked as both a dietary aide and an activity aide. Surveyor shared with NHA-A the concern DA-P's background check was completed that day and not within the four year time frame. NHA-A agreed it should have been done earlier.

Residents Affected - Some

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/06/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor

211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

the nurse and got Resident R1's vital signs. CNA-K came in and got Resident R1 cleaned up and was sent out to the hospital.

CNA-K was the one that called 911. The AM nurse helped to send Resident R1 out around 6:45 AM-7:00 AM. (Surveyor noted CNA-J, in a later interview with Surveyor, denied Resident R1 having an emesis.)LPN-H: Resident R1 slept all night 9/3/2025 and was checked and changed per usual. At around 6:55 AM-7:00 AM CNA-J was getting Resident R1 up and said Resident R1 had an emesis and was weak. CNA-J was getting Resident R1's vital signs and CNA-K called

1. 911. LPN-H was leaving at this time, and the day shift nurse was aware of the situation and was helping to

get Resident R1 sent out to the hospital. LPN-H was under the impression the day shift nurse was doing the send out. (Surveyor noted no documentation was completed by any staff nurse of Resident R1's condition when being sent out and no transfer documentation that should accompany a resident to the hospital was found.)LPN-N: LPN-N was the day shift nurse coming on shift on 9/4/2025. LPN-N remembered overhearing about Resident R1 being sent out. LPN-N was under the impression that the night shift LPN was doing the send out.LPN-C: LPN-C worked with Resident R1 on 9/3/2025 and discussed Resident R1 with NP-D. NP-D was ordering some labs. Resident R1 was constipated and LPN-C gave Resident R1 Milk of Magnesia and Resident R1 had a bowel movement. Resident R1 did not have any emesis and nothing other than constipation was noted on Resident R1's assessment. (Surveyor noted LPN-C did not sign out the administration of the Milk of Magnesia.)NP-D: CNA-K was concerned about Resident R1. Resident R1 seemed more lethargic and was eating less per CNA-K. NP-D told the nurse on the floor that Resident R1 seemed more lethargic than usual and Resident R1 was not feeling well. NP-D ordered labs.Surveyor noted the night shift nurse thought the day shift nurse was caring for Resident R1 and the day shift nurse thought the night shift nurse was caring for Resident R1 at the change of shift on 9/4/2025. Neither nurse documented anything.In a phone interview

on 11/5/2025 at 10:22 AM, NP-D stated the nursing staff as well as CNA-K informed NP-D of Resident R1's change of condition on 9/3/2025. NP-D

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/06/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor

211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited GENEVA LAKE MANOR in LAKE GENEVA, WI for a deficiency under regulatory tag F-F0726 during a complaint investigation conducted on 2025-11-06.

Category: Nursing and Physician Services Deficiencies

The facility was found deficient in the following area: Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 3 deficiencies cited during this inspection of GENEVA LAKE MANOR.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-12-01.