Geneva Lake Manor: Antibiotic Oversight Failures - WI
The admission came during a March 3 inspection visit. The assistant director of nursing, identified in the report only as ADON-F, told the surveyor she had taken over the infection prevention program in October 2024 and was still learning the process. When asked whether every resident placed on an antibiotic had received a McGeer criteria review beforehand, she said that was their goal, but that it had not been done for everyone.
The McGeer criteria are a set of clinical guidelines used in long-term care settings to determine whether a resident's symptoms actually meet the threshold for a likely infection before antibiotics are prescribed. The purpose is to prevent unnecessary antibiotic use, which contributes to drug-resistant infections and can cause harm to patients who don't need the medication.
At Geneva Lake Manor, the process wasn't happening.
The surveyor reviewed monthly infection surveillance logs for January, February, and March of 2025. January's list had 36 resident entries. February had 29. March had 24. In case after case, residents had been started on antibiotics with no completed McGeer form in their records.
One resident, identified as R1, was diagnosed with a urinary tract infection on March 1, had a culture taken the same day, and was started on Macrobid the following morning. No McGeer review had been completed.
Another resident, R151, was diagnosed with a urinary tract infection on February 17 and had a culture taken that day. Six days later, on February 23, a physician called in to change the antibiotic to ciprofloxacin, and nursing notes from February 22 recorded a call about stopping Keflex immediately and switching. There was one additional problem: R151 had never received Keflex. No McGeer review had been completed for any antibiotic given to this resident.
The surveyor brought these findings to the nursing home administrator and director of nursing on March 4. The concern, as the inspector framed it, was direct: residents were being placed on antibiotics without any documentation showing the use met an accepted standard of practice.
Antibiotic stewardship programs exist specifically to prevent this. When antibiotics are given without clear justification, residents face risks from the drugs themselves, and the broader care environment becomes more hospitable to resistant organisms that are harder to treat when a genuine infection does occur. In long-term care, where residents are often older and medically fragile, those consequences fall hardest.
The assistant director of nursing told the inspector the facility uses McGeer criteria and is trying to get it in place more frequently. She said they were working toward completing the form for each resident on an antibiotic and scanning it into the resident record. The surveyor's review of the previous months' logs suggested that effort had not yet produced consistent results.
The deficiency was cited at a level of minimal harm or potential for actual harm, and inspectors noted it potentially affected all 53 residents in the facility. The facility's own infection surveillance policy, last revised in 2017, states that the purpose of infection surveillance is to identify individual cases and trends, guide appropriate interventions, and prevent future infections.
None of that can happen reliably when the baseline documentation isn't being completed before antibiotics are dispensed. The assistant director of nursing had been running the program for five months when inspectors arrived. She told them she was still learning.
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.
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Last verified: November 4, 2026 · Our methodology
Geneva Lake Manor in Lake Geneva, WI was cited for violations during a health inspection on March 17, 2025.
The admission came during a March 3 inspection visit.
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.