Geneva Lake Manor: Immediate Jeopardy Care Failure - WI
That was the morning of September 4, 2025, at Geneva Lake Manor on South Curtis Street. By the time inspectors arrived in November, they had reconstructed what happened through a series of staff interviews that told the same story from different angles, each account making the failure clearer than the last.
The day before, on September 3, a nurse practitioner identified as NP-D had already noticed the resident, referred to in inspection records as R1, was more lethargic than usual and eating less. A CNA had flagged the concern. NP-D ordered labs. A nurse gave R1 Milk of Magnesia for constipation, and R1 had a bowel movement. That nurse, identified as LPN-C, did not document administering the medication. NP-D's assessment that day: R1 seemed off, but labs were pending.
R1 slept through the night, checked and changed as usual, according to the night shift nurse, LPN-H.
Then, around 6:55 in the morning, a CNA identified as CNA-J was getting R1 up when R1 vomited and showed signs of weakness. Another CNA, CNA-K, called 911. LPN-H, the night shift nurse, was at the tail end of her shift. The day shift nurse was coming on. LPN-H told inspectors she was leaving and believed the day shift nurse was handling the send-out. The day shift nurse, LPN-N, told inspectors she remembered overhearing something about R1 being sent out, and was under the impression the night shift nurse was doing the send-out.
R1 left for the hospital at roughly 6:45 to 7:00 AM. No nurse had documented R1's condition. No transfer paperwork accompanied R1 to the hospital.
Inspectors noted the contradiction in CNA-J's account directly. CNA-J, in a later interview, denied that R1 had vomited at all. Every other account said otherwise.
What the inspection record describes is a breakdown at the exact moment a nursing home is supposed to function: the handoff between shifts, when one set of eyes passes responsibility to another. Instead, both nurses stepped back at the same time, each counting on the other to act, and neither did. The resident going to the hospital by ambulance, already lethargic for more than a day, already flagged by a nurse practitioner as declining, left without so much as a note.
CMS rated the violation at the level of Immediate Jeopardy, its most serious classification, meaning inspectors determined the failure had placed the resident at risk of serious harm or death.
The inspection was triggered by a complaint, not a routine survey. Inspectors completed their work on November 6, 2025.
What the record does not contain is what happened to R1 at the hospital, or after. The inspection report ends where the ambulance pulled away.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Geneva Lake Manor from 2025-11-06 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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
Geneva Lake Manor in Lake Geneva, WI was cited for immediate jeopardy violations during a health inspection on November 6, 2025.
That was the morning of September 4, 2025, at Geneva Lake Manor on South Curtis Street.
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.