Geneva Lake Manor: Restraint Failures, Pressure Injuries - WI
The abdominal binder at Geneva Lake Manor was supposed to hold nephrostomy tubes in place to prevent the resident from pulling them out. But when federal inspectors arrived in March, they found the resident had quit using it due to skin irritation while staff remained unaware of the problem.
"I decided on my own that I did not want the rash so have asked staff not to put the binder on," the resident told inspectors on March 4.
That same morning, a certified nursing assistant who had just helped the resident get dressed said the resident was still wearing the binder. The director of nursing admitted she wasn't aware the resident had stopped using the device.
When pressed by inspectors that afternoon, administrators acknowledged they had never assessed whether the abdominal binder constituted a physical restraint or developed a care plan for its use. The nursing home administrator was present during that conversation.
The restraint violation was among multiple serious deficiencies federal inspectors documented at the 211 S Curtis Street facility during a March 17 inspection. The most significant problems involved pressure injury care, where six residents received substandard treatment that in some cases allowed wounds to worsen or develop unnecessarily.
R17 arrived at Geneva Lake Manor in July 2024 with existing wounds but never received a proper admission skin assessment. Within a week, the resident had developed multiple deep tissue injuries across both feet, heels, and tailbone. Documentation was so poor that nurses couldn't consistently identify wound locations or stages.
The right heel and Achilles area progressed from a deep tissue injury to an unstageable pressure injury, then to a Stage 4 wound that exposed tendon. The coccyx wound also became unstageable. A registered dietitian recommended a wound-healing supplement called Arginaid in August, but the facility didn't start it until late October — two and a half months later.
"The RD that had been assigned to the facility did not have confidence in getting their recommendations in place," the regional dietitian supervisor told inspectors by phone.
R47's case followed a similar pattern of neglect. Admitted in October 2024, the resident never got a comprehensive skin assessment. Within a week, nurses documented a Stage 2 pressure injury to the right lateral ankle and an unstageable pressure injury to the right lateral foot, along with moisture-associated skin damage.
The facility readmitted R47 four times after hospitalizations without completing required skin assessments upon return. The ankle wound progressed to unstageable. In February 2025, R47 developed new moisture-associated skin damage to both buttocks that worsened with pressure, but staff failed to classify it as a pressure injury.
R34 developed a Stage 3 pressure injury to the right heel in November 2024 that wasn't properly assessed when discovered. Inspectors observed the resident's heels resting directly on the mattress while the prescribed air mattress sat unplugged.
The facility's own policy required comprehensive skin assessments within eight hours of admission, weekly wound assessments with complete documentation, and prompt implementation of dietitian recommendations. Inspectors found systematic failures across all these requirements.
Beyond pressure injuries, the facility failed to protect residents from choking hazards. R44, who had a history of swallowing difficulties, choked on breakfast sausage in December. The resident vomited after the incident, but nursing staff didn't immediately notify the physician or arrange for swallowing evaluation.
"R44 started to choke on her sausage as she could not swallow it or chew it all the way," a nurse wrote. The resident complained of chest fullness and received antacid medication, but no comprehensive assessment followed.
It took a week before the facility requested a video swallow study, and the order wasn't written until December 27. A speech therapist who later worked with R44 said she wasn't made aware of the December choking incident and couldn't explain the communication breakdown.
The facility also failed to properly manage incontinence care after removing a resident's urinary catheter. R47 had the catheter removed in February but never received a bladder assessment or toileting program to restore continence.
Inspectors observed R47 lying in bed with soiled incontinence briefs, reporting no care since the previous night. The resident asked for a bedside commode to avoid urinating in the brief, but staff hadn't provided one despite the resident's mobility needs requiring a mechanical lift.
"I know when I have to go but the staff do not offer me anything to go to the toilet," R47 told inspectors.
The director of nursing admitted that while staff collected hourly documentation about the resident's voiding patterns, "nothing was done with the information and no toileting program had been developed."
Perhaps most concerning was R13's repeated emergency department visits for nephrostomy tube complications. The resident was sent to the hospital six times in 120 days when the tubes became dislodged, clogged, or infected.
The first incident occurred during a Hoyer lift transfer when the nephrostomy tube "was torn from the stop-cock," leaving urine flowing freely. Staff rigged a temporary collection system using a cut Foley catheter until the resident could be transported for repair.
Subsequent incidents followed a pattern: tubes pulled out during transfers, clogged with debris, or becoming displaced. Despite repeated problems, the facility's abdominal binder solution was never properly assessed as a restraint and was ultimately abandoned by the resident due to skin irritation.
"Some are just not conscientious," R13 told inspectors about staff handling of the tubes. "I will give them instructions if needed to prevent issues with nephrostomy tubes but some just are not willing to learn."
The facility also failed to complete required pre-admission screening for mental health conditions. R37 was admitted with diagnoses including bipolar disorder, depression, anxiety, and PTSD, but didn't receive the mandatory PASARR Level I screening until 73 days after admission — and only after inspectors inquired about it.
The Medicaid Pending Manager who should have completed the screening within days of admission said she "works in 6 other facilities and sometimes doesn't catch everything."
These failures represent a breakdown in basic nursing home operations: proper assessment of residents' needs, implementation of care plans, and monitoring of interventions. The facility's policies outlined appropriate procedures, but staff consistently failed to follow them, leaving vulnerable residents at risk for preventable complications.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 15, 2026 · Our methodology
Geneva Lake Manor in LAKE GENEVA, WI was cited for violations during a health inspection on March 17, 2025.
The abdominal binder at Geneva Lake Manor was supposed to hold nephrostomy tubes in place to prevent the resident from pulling them out.
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.
Frequently Asked Questions
- What happened at Geneva Lake Manor?
- The abdominal binder at Geneva Lake Manor was supposed to hold nephrostomy tubes in place to prevent the resident from pulling them out.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in LAKE GENEVA, WI, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from Geneva Lake Manor or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 525565.
- Has this facility had violations before?
- To check Geneva Lake Manor's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.