Geneva Lake Manor: Nephrostomy Tube Failures - WI
Federal inspectors cited Geneva Lake Manor, a nursing home at 211 S. Curtis Street in Lake Geneva, Wisconsin, for causing actual harm to a resident identified in inspection records as R13. The citation, stemming from a survey completed March 17, 2025, placed the level of harm at the highest category short of immediate jeopardy: actual harm.
Nephrostomy tubes are inserted through the skin directly into the kidney to drain urine when normal urinary tract function is blocked or compromised. They require careful monitoring. When they are not managed correctly, infection follows. Repeated infections mean repeated hospitalizations.
That is what happened to R13.
The inspections surveyor raised the concern directly with the facility's Director of Nursing and its Nursing Home Administrator on March 4, 2025, at 3:34 in the afternoon. The surveyor told both of them, in those terms, that there was a serious concern related to R13's nephrostomy tubes. Six emergency department visits. Infections. Hospitalizations. A pattern that should have triggered an internal response long before a federal inspector walked through the door and named it out loud.
Whether either of them expressed surprise is not recorded in the inspection documents.
What is recorded is the pattern itself. R13 developed infections connected to the nephrostomy tube situation and required hospitalization as a result. Six times. The inspection report does not specify how long R13 had been a resident, how many months those six visits were spread across, or what interventions, if any, the facility attempted between trips to the emergency department. It states the visits happened, that infections were involved, and that the surveyor considered the situation serious enough to address it face-to-face with the facility's two top administrators.
Six emergency department visits for the same resident with the same tubes represents a system that did not catch what was happening, or caught it and could not stop it, or did not try hard enough to stop it. The inspection record does not say which. It says the visits happened and calls the situation a serious concern.
For R13, each of those trips meant an ambulance or a transport, an emergency room, unfamiliar staff, the disruption and fear that comes with acute medical crisis, and then a return to the same facility where the problem had not been resolved. And then, at some point, another infection. Another trip.
The deficiency was cited under the category of actual harm, meaning inspectors determined R13 suffered real injury as a result of the facility's failures, not theoretical risk but documented consequence.
Geneva Lake Manor's plan of correction is not included in the publicly available inspection narrative. Residents or families seeking information about how the facility intends to address the deficiency are directed to contact the nursing home or the Wisconsin state survey agency directly.
What the inspection record does not contain is any indication that the facility identified the pattern on its own, escalated it internally, or changed its approach to R13's care before a federal surveyor arrived and made the problem impossible to ignore. The surveyor had to tell the Director of Nursing and the Administrator that a resident had been sent to the emergency department six times. That is what it took.
R13 is still identified only by a code in federal inspection documents. The six emergency department visits are a number in a report. The infections are described in a clause. But for R13, each one was a night, or several nights, away from whatever counted as home, in pain, sick from an infection that the place responsible for that care had not prevented, again.
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 6, 2026 · Our methodology
Geneva Lake Manor in Lake Geneva, WI was cited for violations during a health inspection on March 17, 2025.
Federal inspectors cited Geneva Lake Manor, a nursing home at 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.