Geneva Lake Manor: Wound Care Nutrition Delays - WI
The resident, identified in inspection records as R17, needed a nutritional supplement called Arginaid to support wound healing. The registered dietician assigned to the facility made that recommendation in writing. Then again the following month. Then again the month after that. Nobody ordered it.
Federal inspectors who visited the facility on March 17, 2025 found the delay had caused actual harm.
The dietician first formally documented the Arginaid recommendation on October 9, 2024, noting in a progress note that a daily dose would aid in wound healing. Inspectors reviewed the records and found that was the third consecutive month the dietician had made that same recommendation. The order was finally initiated on October 30, 2024 — more than two and a half months after it had first been suggested.
When inspectors contacted RD-W, the regional supervisor for the facility's dieticians, she described a system that relied on the dietician speaking up and following through. The dietician was expected to visit the facility two to three times a month, document monthly on weight and eating habits, and follow up within 48 hours to confirm recommendations had been put in place. RD-W said the dietician would receive wound reports from the director of nursing or the wound nurse, then write a progress note within 24 hours.
When the inspector told RD-W that R17's recommendations had gone unaddressed for over two months, the supervisor's explanation was brief. The dietician assigned to the facility, RD-W said, "did not have confidence in getting their recommendations in place."
That was the whole answer. A staff member lacked confidence, so a resident went without a supplement for ten weeks while their wounds worsened.
By February 3, 2025, R17's wounds had progressed significantly. A registered nurse documented that the resident had been assessed after a report of moisture-associated skin damage to both buttocks. What the nurse found was extensive. The left buttock had two areas of denuded skin, with a dermatitis-related ulcer at the twelve o'clock position of the wound. That ulcer showed 80 percent granulated tissue and 20 percent slough, with irregularly shaped edges rolled back and measuring 3 centimeters by 2.5 centimeters. The surrounding skin was denuded, with partial thickness damage and blanchable redness.
The right buttock was no better. A partial thickness wound measured 4 centimeters by 3.3 centimeters, also with irregular, rolled-back edges and denuded skin.
Inspectors classified the harm level as actual harm. The deficiency affected some residents at the facility.
What the inspection report captures is a failure that repeated itself month after month without anyone stopping it. The dietician wrote the recommendation. The dietician wrote it again. The dietician wrote it a third time. The system RD-W described, with its 48-hour follow-up window and monthly documentation, did not catch that the recommendations were sitting unread, or read and ignored. Nobody escalated. Nobody asked why the order hadn't been placed.
The regional supervisor's explanation, that the dietician lacked confidence, raises a question the inspection report does not answer: who was responsible for noticing that the same recommendation had appeared three months in a row without any action?
R17's wounds were still present when inspectors arrived.
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 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 as R17, needed a nutritional supplement called Arginaid to support wound healing.
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.