Geneva Lake Manor: No Charge Nurse on Duty Shifts - WI
A federal inspection completed March 17 found that the 53-bed facility on South Curtis Street had not designated a charge nurse on its nursing staff schedules for any tour of duty. The deficiency was cited as affecting all 53 residents.
When a surveyor sat down with the facility's nursing scheduler on the afternoon of February 27 and asked a straightforward question, how do you know who the charge nurse is at any given time, the answer was not straightforward. During the day, the scheduler explained, the Director of Nursing or the Assistant Director of Nursing are in the building. On the evening shift, the Nurse Educator is usually there. Otherwise, there is an on-call person listed at the bottom of the schedule page, reachable by phone.
The surveyor pressed: who in the building is actually labeled as charge nurse during each shift?
The answer was that staff know to call the on-call person.
That on-call person is not in the building. They are a name at the bottom of a page, available by telephone.
A charge nurse is the clinical authority on a floor during a shift. When a resident deteriorates, when a family member demands answers at 11 p.m., when a medication error surfaces, when two aides disagree about what a doctor ordered, the charge nurse is the person who decides. At Geneva Lake Manor, inspectors found no documentation establishing who held that role on any shift across a full month of schedules.
The surveyor reviewed those 30 days of schedules on the morning of February 27. That afternoon, after speaking with the scheduler, the inspector brought the finding to the Nursing Home Administrator, the Director of Nursing, and the Assistant Nursing Home Administrator together.
The facility offered no explanation.
That phrase appears in the inspection report without elaboration: "The Facility did not provide any additional information as to why it did not ensure there was a designated charge nurse for each tour of duty."
Not a partial explanation. Not a disputed explanation. None.
The violation was rated at the lower end of the harm scale, minimal harm or potential for actual harm. That rating reflects what inspectors could document, not a ceiling on what the arrangement risked. A facility where the evening shift's answer to "who is in charge" is "call this number" is a facility where the first minutes of a medical emergency may involve someone figuring out who to phone before anyone decides what to do.
Geneva Lake Manor is a 53-bed skilled nursing facility. The inspection covered all of its residents.
The scheduler's description of how the facility actually operated, the DON by day, the Nurse Educator most evenings, a phone number otherwise, suggests the facility had informal coverage arrangements that never made it onto paper. Whether those arrangements worked in practice is not something inspectors documented. What they documented is that for a month of shifts, no schedule said who was responsible.
For the residents at Geneva Lake Manor, the practical meaning is this: on any given evening, the person with clinical authority over their care was not identified on any document in the building. If something went wrong and staff needed to escalate, the path ran to a phone number at the bottom of a page.
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.
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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 deficiency was cited as affecting all 53 residents.
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.