Geneva Lake Manor: Restraint Assessment Failure - WI
The nursing director, identified in inspection records as DON-B, explained to a surveyor on March 4 how the binder came to be used in the first place. The resident, identified as R13, had been pulling at his nephrostomy tubes during Hoyer lift transfers. The first couple of times it happened, DON-B said, she obtained an abdominal binder to hold the tubes in place during those transfers.
It was a practical solution to a serious problem. Nephrostomy tubes drain urine directly from the kidneys, and dislodging them is not a minor event.
What DON-B did not know, as of that morning, was that R13 had already made his own decision about the binder. He told the surveyor at 9:30 a.m. that he wasn't using it anymore. It was too tight. He had developed a rash. He had asked staff not to put it on him.
Nine minutes later, the certified nursing assistant who had helped R13 get ready that same morning told the surveyor the opposite. Asked about the binder, CNA-K said, "ya he wear it."
CNA-K had just finished helping R13. The binder had not gone on. CNA-K either did not notice, did not know it was supposed to be part of the routine, or did not consider its absence worth mentioning.
When DON-B learned from the surveyor that R13 had stopped wearing the binder because of the rash, her response was that she would have to talk to R13 about skin protection options. The nephrostomy tubes were now unsecured. The problem the binder was meant to solve had not gone away.
That afternoon, the surveyor returned to a different question. Had the abdominal binder ever been formally assessed? DON-B said it had not been assessed and had not been considered a restraint. The nursing home administrator was present in the room when the surveyor said that was a concern.
The inspection report does not record any response from the administrator.
The surveyor's concern was specific. A device that restricts a resident's movement or holds a body part in a fixed position can meet the definition of a physical restraint, and facilities are required to assess such devices, weigh their risks and benefits, and build a care plan around whatever they decide. None of that had happened here. The binder had been introduced as a workaround during transfers, the resident had developed a rash and stopped wearing it, a nursing assistant believed he was still wearing it, the director of nursing didn't know he had stopped, and the device had never been formally evaluated at all.
By the time surveyors left the facility, Geneva Lake Manor had provided no additional documentation and no explanation for why the assessment had not been done.
R13 was left in the position of having made a unilateral medical decision because the facility had not created a structure for making it with him. The rash was his reason. Whether there was a safer alternative, whether the risk of tube displacement outweighed the risk to his skin, whether a different kind of binder or a different protocol might have worked — none of those questions had been formally asked, and none had been answered.
He decided on his own that he did not want the rash. So he asked staff not to put the binder on. And for a period of time that the inspection report does not specify, the staff member who helped him each morning thought he was still wearing it.
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.
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Last verified: November 3, 2026 · Our methodology
Geneva Lake Manor in Lake Geneva, WI was cited for violations during a health inspection on March 17, 2025.
The nursing director, identified in inspection records as DON-B, explained to a surveyor on March 4 how the binder came to be used in the first place.
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.