Inspection Report

Geneva Lake Manor: Pressure Injury Care Failures - WI

November 2, 2025

Lake Geneva, WI

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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.

Repeated Medical Device Complications

Another resident required six emergency department visits over 120 days due to complications with bilateral nephrostomy tubes—medical devices that drain urine directly from the kidneys when normal urinary pathways are blocked. The tubes repeatedly became dislodged, displaced, or malfunctioned, requiring emergency interventions and hospital procedures to replace them.

Nephrostomy tubes require careful handling during all care activities, particularly during transfers. The resident used a mechanical lift for transfers, which increases the risk of catching or pulling tubes if proper precautions are not taken. Documentation revealed that some incidents occurred during Hoyer lift transfers when tubes became caught or pulled.

In January 2025, facility staff obtained an abdominal binder to secure the tubes and prevent displacement. However, inspectors discovered the resident had stopped wearing the binder due to skin irritation, and staff were unaware this protective measure was no longer in use. The facility did not assess the binder as a potential restraint device or develop alternative solutions to prevent tube displacement while addressing the skin irritation concern.

One incident resulted in a urinary tract infection requiring week-long hospitalization for intravenous antibiotics. Each tube displacement or dislodgement created infection risk, required emergency interventions, and subjected the resident to additional medical procedures. The repeated nature of these incidents indicated systemic issues with staff training, care planning, and device management protocols.

Additional Issues Identified

Inspectors documented several other significant deficiencies. One resident did not receive a required Pre-Admission Screening and Resident Review (PASARR) assessment for mental health conditions at the time of admission, despite having documented diagnoses including bipolar disorder, depression, anxiety, and PTSD. This screening, completed two months late, is federally required to ensure residents with mental health conditions receive appropriate services.

After removal of an indwelling urinary catheter, another resident did not receive a comprehensive bladder assessment or toileting program to restore continence. Despite collecting hourly documentation of voiding patterns, nursing staff did not analyze this information to develop a prompted voiding schedule. The resident reported awareness of the need to urinate but stated staff did not offer alternatives to using incontinence briefs.

Registered dietician recommendations for wound healing supplements went unimplemented for over two months for multiple residents with serious pressure injuries. The supplement Arginaid, specifically designed to support wound healing through enhanced protein and nutrients, was recommended in August but not ordered until late October—a critical delay during active wound deterioration.

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

Editorial Standards

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 21, 2026 · Our methodology

Quick Answer

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.

Frequently Asked Questions

What happened at Geneva Lake Manor?

## Pressure Injury Care Falls Short of Standards Inspectors identified systemic failures in pressure injury prevention and treatment affecting six residents.

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.