Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Geneva Lake Manor
Lake Geneva, WI · 60 certified beds · Last Life Safety survey March 17, 2025
CMS Certification Number 525565 · first certified May 1995
Ownership
Operated by WISCONSIN ILLINOIS SENIOR HOUSING, INC. · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within WI
23 citations — more than 67% of the 323 certified nursing homes in WI. Compared within WI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 9 citations; the earlier surveys in the window averaged 7. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (April 2026 to June 2026), and past the point by which nine in ten WI facilities have been surveyed. This facility’s last Life Safety survey was March 2025. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 516 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
3 of the 23 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
7 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 23 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 23 |
| Median facility in WI | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| September 12, 2022 | 6 |
| January 16, 2024 | 8 |
| March 17, 2025 | 9 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2025-03-17 |
| K-0324 | Provide properly protected cooking facilities. | 2 | 2024-01-16 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2024-01-16 |
| K-0781 | Have restrictions on the use of portable space heaters. | 1 | 2022-09-12 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2025-03-17 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 1 | 2025-03-17 |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | 1 | 2024-01-16 |
| E-0031 | Provide emergency officials' contact information. | 1 | 2025-03-17 |
What the citations cover
- Smoke Deficiencies 10
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Miscellaneous Deficiencies 3
- Emergency Preparedness Deficiencies 3
- Other 3
| Category | Citations |
|---|---|
| Smoke Deficiencies | 10 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Miscellaneous Deficiencies | 3 |
| Emergency Preparedness Deficiencies | 3 |
| Services Deficiencies | 2 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
March 17, 2025 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (April 17, 2025) |
| E-0031 | Provide emergency officials' contact information. | Deficient, Provider has date of correction (April 9, 2025) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (April 10, 2025) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (April 7, 2025) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (April 11, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 15, 2025) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (April 14, 2025) |
| K-0522 | Have an externally vented heating system. | Deficient, Provider has date of correction (April 14, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (April 16, 2025) |
January 16, 2024 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (February 14, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (February 14, 2024) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (February 14, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (February 14, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (February 14, 2024) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (February 14, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (February 14, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (February 14, 2024) |
September 12, 2022 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (September 28, 2022) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (September 28, 2022) |
| K-0361 | Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Deficient, Provider has date of correction (September 28, 2022) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (September 28, 2022) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (September 28, 2022) |
| K-0781 | Have restrictions on the use of portable space heaters. | Deficient, Provider has date of correction (September 28, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.