Geneva Lake Manor: Bed Hold Notice Failures - WI
The resident, identified in inspection records as R13, had been living at the 211 S. Curtis Street facility since November 2024, most recently readmitted after a prior hospital stay. His medical history included MRSA, Parkinsonism, type 2 diabetes with diabetic nephropathy, and paralysis affecting his right dominant side following a stroke. He was, by the facility's own assessment, fully cognitively intact, with a perfect score on the mental status screening completed just two weeks after his February 14 transfer. He understood what was being said to him. He could make his own decisions. Nobody told him his rights anyway.
Inspectors requested documentation showing the facility had provided R13 and his responsible party with a bed hold notice at the time of the hospital transfer. What they received instead was a consent form dated November 19, 2024, the day of R13's most recent admission. R13 had signed it and checked the box accepting a bed hold. That form was months old. It was not a notice issued at the time of transfer.
The Director of Nursing, identified in the report as DON-B, confirmed it on February 27. "November 19th was the last admission for R13," DON-B told the surveyor, "and the form given is all they have." A week later, on March 4, DON-B was more direct: they do not have any paperwork provided at the time of transfer.
The Social Worker, identified as SW-S, told inspectors that bed hold notices are the responsibility of nursing staff. Nursing staff, it appears, had not done them.
R13 was not the only resident affected. A second resident, R47, had been sent to the hospital on four separate occasions: October 30, 2024, December 24, 2024, January 9, 2025, and January 19, 2025. Inspectors asked for bed hold notices for all four dates. DON-B said there weren't any scanned into R47's medical record. There weren't any unscanned ones either. "They were not able to find any that had not been scanned in," the inspection report states.
Four hospital transfers. Four gaps in the record. No documentation that R47 was ever told, on any of those occasions, that a bed was being held.
The violation was cited at the lowest level of harm, meaning inspectors determined there was minimal harm or potential for actual harm rather than documented injury. But the practical stakes of a missing bed hold notice are not abstract. Residents who don't know their bed is being held may not know to push for its return. Families who aren't notified may not know to ask. The paperwork is the mechanism by which a nursing home resident, already sick enough to need emergency care, is told: you still have a place here.
Geneva Lake Manor's own form acknowledged this. R13 had signed one. He had checked the right box. The facility simply did not repeat the process when it mattered, on the day the ambulance came, when his tubes were leaking and the smell had turned, when he was being transferred out the door.
DON-B confirmed the missing paperwork on March 4 at 7:56 in the morning. The inspection had begun weeks earlier. In the time between, nobody had located the notices, because there were none to locate.
R13 returned from the hospital. The inspection report does not say when, or whether the bed he had paid to hold was still there when he did.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Geneva Lake Manor from 2025-03-17 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 4, 2026 · Our methodology
Geneva Lake Manor in Lake Geneva, WI was cited for violations during a health inspection on March 17, 2025.
The resident, identified in inspection records as R13, had been living at the 211 S.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.