Geneva Lake Manor: Choking Risk After Failed Assessment - WI
The resident, identified in inspection records only as R44, had swallowing concerns before the choking incident. After it happened, the facility conducted what inspectors described as a review that fell short of thorough. Staff had not determined what size food she should be eating or whether her condition had changed in ways that required a different approach to her meals.
The inspection, completed March 17, 2025, cited the facility for failing to fully assess R44's swallowing abilities following the choking episode.
Swallowing disorders are common among nursing home residents, particularly those with neurological conditions, stroke histories, or advanced age. When a person chokes, it signals something has gone wrong in the coordination of muscles that move food from the mouth to the stomach. Without a proper evaluation after such an incident, staff have no reliable basis for knowing what texture of food is safe, whether liquids need to be thickened, or whether the resident needs to be fed differently or referred for a formal swallowing study.
None of that work was done here.
Inspectors noted the potential consequence directly: without further assessment of R44's capabilities, she faced a risk of choking again. The harm level was classified as minimal harm or potential for actual harm, meaning inspectors believed the failure had not yet produced serious injury but left the door open for it.
The finding affected few residents, according to the inspection record.
What the report describes is a gap between something going wrong and the response that should follow it. A choking incident is not a routine event in a care setting. It is a signal. When a resident who already had documented swallowing concerns chokes, the expected response is to stop and reassess, to bring in the right people, to ask whether the current meal plan is still appropriate. The facility did not do that, at least not completely.
The inspection record does not describe what R44's underlying condition was, how serious the choking episode appeared at the time, or whether she received any immediate medical attention afterward. It does not name the staff members involved or describe what the incomplete review actually examined. What it records is the absence: no thorough assessment, no determination of appropriate food size, no documented evaluation of what R44 could and could not safely eat.
Dining is one of the few areas of daily life where nursing home residents retain something close to normalcy. Meals mark time. They are social. They are connected to comfort and identity. For a resident with swallowing problems, every meal also carries a specific physical risk, one that can be managed with the right information and preparation, and that becomes harder to manage without it.
R44 was eating without that information.
Geneva Lake Manor is located at 211 S. Curtis Street in Lake Geneva, a small city in Walworth County in southeastern Wisconsin. The inspection was conducted under the federal survey process administered by the Centers for Medicare and Medicaid Services, which certifies nursing homes that receive Medicare and Medicaid funding.
The facility was given the opportunity to submit a plan of correction. The inspection record does not describe what steps, if any, were taken for R44 between the choking incident and the date inspectors arrived.
Whether she choked again in that interval, the record does not say.
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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Last verified: November 6, 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 only as R44, had swallowing concerns before the choking incident.
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.