Geneva Lake Manor

In the surveyor’s words

From the most serious findings on record at Geneva Lake Manor, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 27, 2026

  Based on interview and record review, the facility failed to provide adequate supervision to prevent an elopement from occurring for 1 of 3 residents at risk for elopement out of a sample of 12 (R1). R1 has a history of elopement and is at risk of wandering. The facility failed to implement care planned interventions and failed to ensure exits were secured resulting in R1 being able to exit the facility through an exit door without staff knowledge. The facility's failure to supervise a resident and implement care planned interventions allowed R1 to elope from the facility. This created a finding of immediate jeopardy that began on 7/10/26. […]

• Immediate jeopardy, isolatedF684Nov 6, 2025

  Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) based on their comprehensive assessment for 1 (R1) of 3 residents reviewed.On 9/3/2025, R1 experienced a change of condition with increased lethargy, not wanting to eat, having a small emesis, and no bowel movement for three days. No documentation of an assessment by facility staff including vital signs, was found with the change of condition. No assessment or documentation was found from facility nursing staff of R1 having multiple emesis. […]

• Immediate jeopardy, isolatedF684Nov 12, 2024

  Based on record review and interviews, the facility did not ensure resident's experiencing a medical change in condition, received appropriate treatment and care, per standards of practice consistent with N6 Wisconsin Nurse Practice Act. This was discovered with 2 (R13 and R6) of 5 residents reviewed with a medical change in condition. * On [DATE], at 3:15 PM, R13 developed a high fever that was not resolved with medication. R13's blood sugar was to high to register on a testing meter. Their pulse and oxygen saturations were erratic. They had rapid gargled breathing. There is no evidence their symptoms were communicated to a medical provider for consultation and treatment. They experienced a cardiac arrest and passed away in the facility on [DATE], at 7:35 PM. […]

• Actual harm, patternF686Mar 17, 2025

  Based on observation, interview, and record review, the facility did not ensure residents received care consistent with professional standards of practice to prevent development of pressure injuries or received care to promote healing and prevent new ulcers from developing for 6 (R17, R47, R34, R19, R26, and R36) of 6 residents reviewed with pressure injuries or at risk for developing pressure injuries. *R17 did not have a comprehensive skin assessment on admission on 7/19/2024. On 7/26/2024, wound documentation included a Deep Tissue Injury (DTI) to the right lateral foot, a DTI to the right Achilles and heel, a DTI to the coccyx, a DTI to the left heel, and a DTI to the left Achilles. […]

• Actual harm, isolatedF691Mar 17, 2025

  Based on interview and record review, the Facility did not ensure a resident received treatment and care in accordance with professional standards of practice to prevent the need for repeated medical interventions. This was discovered with 1 (R13) of 14 residents reviewed for quality of care. In the last 120 days R13 has been sent to the emergency department six times for complications related to nephrostomy tubes (thin, flexible tubes inserted directly into the kidney to drain urine when the natural urinary tract is blocked). Findings include: R13 was originally admitted to the facility on [DATE] and most recently readmitted [DATE] after a hospital stay. […]