Geneva Lake Manor: Resident Left Without Toilet Access - WI
The resident, identified in inspection records only as Resident 47, uses a mechanical lift to move. The lift does not fit inside the bathroom. But the resident told a federal surveyor that staff could have placed a bedside commode next to the bed and used the lift to transfer them onto it. Nobody did.
The surveyor asked whether staff had at least offered a bedpan. They had tried once. It caused pain because it was not positioned straight underneath the resident. Nobody tried again after that.
What the inspection report does not show is any evidence that staff offered a consistent alternative. No bedside commode. No toileting schedule. No plan of any kind.
The deeper problem, according to the March 2025 inspection, was what happened after Resident 47's urinary catheter was removed. A catheter handles the problem mechanically. When it comes out, a resident who cannot independently access a toilet needs a new plan, typically built around a bladder assessment that identifies when and how often the person needs to go and what assistance they require. That assessment was never done.
On March 4, at 3:32 in the afternoon, the surveyor sat down with Geneva Lake Manor's nursing home administrator and director of nursing and told them directly: no comprehensive bladder assessment had been completed after the catheter was removed. No toileting program had been developed to meet Resident 47's needs.
The administrator and director of nursing did not dispute it.
Geneva Lake Manor is a nursing home at 211 South Curtis Street in Lake Geneva, a small city in Walworth County about an hour south of Milwaukee. The March 17, 2025 inspection was a standard health survey conducted by the Centers for Medicare and Medicaid Services.
The violation was cited at the lowest level of harm on the federal scale, meaning inspectors determined the resident experienced minimal harm or only the potential for harm. That designation matters for how regulators respond. It does not change what Resident 47 described.
The resident said clearly, in their own words, that they know when they need to go. The knowledge is there. The body is giving the right signals. What was missing was a staff response, and a care plan built around the reality of how this particular person moves through the world.
A mechanical lift is not an unusual piece of equipment in a nursing home. Residents who cannot bear weight or transfer independently rely on them constantly. The existence of the lift was not a surprise to anyone. The bathroom not accommodating it was not new information. The question of how Resident 47 was supposed to use the toilet was a question that existed from the moment the catheter came out, and possibly before.
The inspection record does not say how long the catheter had been removed before the surveyor's visit. It does not say how many times Resident 47 had been incontinent waiting for help that did not come. It does not say whether the resident had raised the issue with staff before speaking to the surveyor.
What it says is that Resident 47 told the surveyor they know when they have to go. And that staff do not offer anything.
The plan of correction, if one was submitted, is not included in the inspection materials reviewed for this article. Geneva Lake Manor has not been contacted for comment.
Resident 47 is still there.
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 5, 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 Resident 47, uses a mechanical lift to move.
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.