Geneva Lake Manor
Geneva Lake Manor in LAKE GENEVA, WI — inspection on November 6, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
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
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/06/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Geneva Lake Manor
211 S Curtis St Lake Geneva, WI 53147
SUMMARY STATEMENT OF DEFICIENCIES
jeopardy to resident health or safety
the nurse and got R1's vital signs. CNA-K came in and got R1 cleaned up and was sent out to the hospital.
CNA-K was the one that called 911.
The AM nurse helped to send R1 out around 6:45 AM-7:00 AM. (Surveyor noted CNA-J, in a later interview with Surveyor, denied R1 having an emesis.)LPN-H: 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 R1 up and said R1 had an emesis and was weak. CNA-J was getting R1's vital signs and CNA-K called
- LPN-H was leaving at this time, and the day shift nurse was aware of the situation and was helping to
get 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 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 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 R1 on 9/3/2025 and discussed R1 with NP-D. NP-D was ordering some labs. R1 was constipated and LPN-C gave R1 Milk of Magnesia and R1 had a bowel movement. R1 did not have any emesis and nothing other than constipation was noted on 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 R1. R1 seemed more lethargic and was eating less per CNA-K. NP-D told the nurse on the floor that R1 seemed more lethargic than usual and R1 was not feeling well. NP-D ordered labs.Surveyor noted the night shift nurse thought the day shift nurse was caring for R1 and the day shift nurse thought the night shift nurse was caring for 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 R1's change of condition on 9/3/2025. NP-D
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/06/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Geneva Lake Manor
211 S Curtis St Lake Geneva, WI 53147
SUMMARY STATEMENT OF DEFICIENCIES
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.