Geneva Lake Manor: Pressure Injury Care Failures - WI
Multiple Serious Care Failures Identified at Lake Geneva Nursing Facility
LAKE GENEVA, WI - State inspectors documented significant deficiencies in wound care, safety protocols, and medical device management at Geneva Lake Manor during a March 2025 inspection, with multiple residents experiencing preventable complications that required emergency interventions.
Pressure Injury Care Falls Short of Standards
Inspectors identified systemic failures in pressure injury prevention and treatment affecting six residents. The most concerning case involved a resident admitted in July 2024 with existing skin conditions who developed multiple severe pressure injuries that progressively worsened under facility care.
One resident, admitted with cellulitis and venous insufficiency, did not receive a comprehensive skin assessment upon admission. Within one week of admission, staff documented five separate deep tissue injuries to various body locations including the heels, coccyx, and foot. These wounds subsequently progressed to more severe stages—including Stage 4 and Unstageable pressure injuries—despite being under facility care.
Medical records revealed the right heel and Achilles area developed a deep tissue injury that later progressed to a Stage 4 pressure injury, indicating full-thickness tissue loss with exposed tendon. The coccyx wound progressed to an Unstageable injury. A right medial foot injury that developed in August also progressed from deep tissue injury to Stage 3 before eventually healing.
Pressure injuries develop when sustained pressure restricts blood flow to tissue, causing cell death and tissue breakdown. Stage 4 injuries represent the most severe form, penetrating through skin and fat into muscle and potentially bone. Unstageable wounds contain so much dead tissue that the depth cannot be determined without removal of that tissue. These severe injuries significantly increase infection risk, extend healing time, and can lead to life-threatening complications including sepsis.
The facility's documentation revealed multiple systemic problems: wounds were not consistently staged according to medical standards, weekly comprehensive assessments were not completed as required, and depth measurements were frequently omitted. In several instances, no wound documentation appeared in records for periods of two to three weeks, violating the facility's own policy requiring weekly assessment.
Delayed Response to Choking Incident
A resident with known swallowing difficulties experienced a choking episode on December 19, 2024, that did not receive appropriate immediate follow-up. The resident choked on breakfast sausage, experienced a small emesis, and complained of chest fullness. Despite these symptoms, nursing staff did not immediately notify the physician or initiate a referral to speech therapy for swallowing evaluation.
The medical significance of choking episodes in individuals with swallowing difficulties cannot be overstated. Dysphagia, or difficulty swallowing, increases the risk of aspiration—when food or liquid enters the airway instead of the esophagus. Aspiration can lead to aspiration pneumonia, a serious and potentially fatal lung infection, particularly dangerous for elderly residents.
Following the December incident, no dietary modifications were made and no speech therapy evaluation was ordered until December 26—one week later. The resident did not receive a comprehensive speech therapy evaluation until January 8, 2025, nearly three weeks after the choking episode. During this intervening period, the resident remained at elevated risk for another choking incident.
Speech therapy evaluation protocols following choking incidents are standard medical practice because they identify specific swallowing impairments and determine appropriate food textures and supervision needs. The delay meant the resident continued eating regular-textured foods, including items like sausage that pose higher choking risks, without proper assessment of swallowing function or implementation of safety measures.
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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Geneva Lake Manor in Lake Geneva, WI was cited for violations during a health inspection on March 17, 2025.
## Pressure Injury Care Falls Short of Standards Inspectors identified systemic failures in pressure injury prevention and treatment affecting six residents.
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.