Cycle 1
Health 2025-05-07 · Fire 2025-05-07
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Lake Geneva, WI
Golden Years Of Lake Geneva
4-star overall rating with 5-star inspections with 3 fire-safety deficiencies in the latest cycle
611 Harmony Drive, Lake Geneva, WI
(262) 249-1960
Overall
4 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
54
Certified beds
Average residents
28
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2018-06-18
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.36
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
1.15
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
4.54
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
7.05
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
2.51
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
6.02
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.85
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.19
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.38
CMS adjusted RN staffing hours
Adjusted total hours
7.13
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
135
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
82.4
Composite VBP score used to determine payment impact.
Payment multiplier
1.0263
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.25
Baseline 18.20% · Performance 18.07% · Measure score 7.25 · Achievement 7.25 · Improvement 0.59
Healthcare-associated infections
7.47
Baseline 6.19% · Performance 5.60% · Measure score 7.47 · Achievement 7.47 · Improvement 4.42
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
10
Performance 6.74 hours · Measure score 10 · Achievement 10 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.6% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 203 · Observed rate 11.33% · Lower 95% interval 8.41% |
| Discharge to community | 63.11% |
50.57%
12.5 pts better
|
Better than the National Rate · Eligible stays 187 · Observed rate 58.82% · Lower 95% interval 55.94% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 96% |
95.27%
0.7 pts better
|
Numerator 168 · Denominator 175 |
| Falls with major injury | 0.57% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 175 |
| Discharge self-care score | 30.28% |
53.69%
23.4 pts worse
|
Numerator 43 · Denominator 142 |
| Discharge mobility score | 38.73% |
50.94%
12.2 pts worse
|
Numerator 55 · Denominator 142 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 175 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.6% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 152 · Observed rate 2.63% · Lower 95% interval 2.99% |
| Staff COVID-19 vaccination coverage | 2.8% |
8.2%
5.4 pts worse
|
Numerator 3 · Denominator 107 |
| Staff flu vaccination coverage | 17.24% |
42%
24.8 pts worse
|
Numerator 20 · Denominator 116 |
| Discharge function score | 39.44% |
56.45%
17 pts worse
|
Numerator 56 · Denominator 142 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 34 · Denominator 34 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 97 · Denominator 97 |
| Resident COVID-19 vaccinations up to date | 49.43% |
25.2%
24.2 pts better
|
Numerator 43 · Denominator 87 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.6
0.7 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.9 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.7 |
2.2
0.5 pts worse
|
1.8
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 3.1 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.7%
4.3 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.7% |
3.2%
5.5 pts worse
|
3.3%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 10.0% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.6% |
5.0%
3.4 pts better
|
11.4%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.6% |
| Percentage of long-stay residents who lose too much weight | 10.5% |
4.9%
5.6 pts worse
|
5.4%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.0% |
16.6%
2.6 pts better
|
19.6%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.0% |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.8% |
21.1%
5.3 pts better
|
16.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.3% |
17.3%
6 pts worse
|
14.9%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.9% |
2.3%
0.6 pts worse
|
1.0%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 14.1% |
3.0%
11.1 pts worse
|
1.7%
12.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 48.6% |
25.5%
23.1 pts worse
|
19.8%
28.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 48.6% |
| Percentage of long-stay residents with pressure ulcers | 8.6% |
5.5%
3.1 pts worse
|
5.1%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
86.8%
13.2 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.4% |
15.0%
1.6 pts better
|
12.0%
1.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.4% · Observed 12.2% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.0% |
1.3%
1.7 pts worse
|
1.6%
1.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 4.1% · Q3 1.4% · Q4 2.6% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.2% |
82.2%
4 pts better
|
79.7%
6.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.3% |
22.7%
1.6 pts worse
|
23.9%
0.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.3% · Observed 21.2% · Expected 20.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-08 · Fire 2024-02-08
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
9 fire-safety deficiencies
Top issue: Miscellaneous (3 deficiencies)
Cycle 3
Health 2022-11-10 · Fire 2022-11-10
5 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-07
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-05-22
F · Potential for more than minimal harm
2025-05-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-21
D · Potential for more than minimal harm
2025-05-07
K925 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Corrected 2025-05-22
F · Potential for more than minimal harm
2024-02-08
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-02-28
F · Potential for more than minimal harm
2024-02-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-02-28
F · Potential for more than minimal harm
2024-02-08
K791 · Miscellaneous Deficiencies
Fire Safety
Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency.
Corrected 2024-02-22
E · Potential for more than minimal harm
2024-02-08
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-02-08
E · Potential for more than minimal harm
2024-02-08
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-02-28
E · Potential for more than minimal harm
2024-02-08
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-02-08
D · Potential for more than minimal harm
2024-02-08
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-02-08
D · Potential for more than minimal harm
2024-02-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-02-08
C · Minimal harm
2024-02-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-08
F · Potential for more than minimal harm
2022-11-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-11-09
F · Potential for more than minimal harm
2022-11-10
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2022-11-09
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-01-09
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-02-11
D · Potential for more than minimal harm
2024-02-08
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-02-09
D · Potential for more than minimal harm
2024-02-08
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-02-09
D · Potential for more than minimal harm
2024-02-08
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-03-01
C · Minimal harm
2024-02-08
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-02-09
C · Minimal harm
2024-02-08
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-02-09
D · Potential for more than minimal harm
2022-11-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-11-11
D · Potential for more than minimal harm
2022-11-10
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2022-11-22
D · Potential for more than minimal harm
2022-11-10
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-11-11
D · Potential for more than minimal harm
2022-11-10
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-11-11
D · Potential for more than minimal harm
2022-11-10
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-12-01
Penalties and ownership
What sits behind the stars
Ownership
Austin, Jeffrey
5% Or Greater Direct Ownership Interest · Individual
Stankevitz, Jonathan
5% Or Greater Direct Ownership Interest · Individual
Austin, Linda Susan
5% Or Greater Direct Ownership Interest · Individual
Austin, Jeffrey
W-2 Managing Employee · Individual
Stankevitz, Jonathan
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Geneva Lake Manor
Lake Geneva, WI
1-star overall rating with 1-star inspections with $201,107 in total fines with 29 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Williams Bay Health Services
Williams Bay, WI
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Lakeland Health Care Ctr
Elkhorn, WI
3-star overall rating with 2-star inspections with abuse icon flag with $127,260 in total fines with 10 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
Jump out