Geneva Lake Manor: Medication Monitoring Failures - WI
That exchange, on February 27, took place during a March 2025 inspection of the 211 South Curtis Street facility. What surveyors documented across multiple residents was a pattern: medications that required close monitoring, care plans that called for that monitoring, and no evidence in the medical records that any of it happened.
One resident, identified in inspection records as R34, was taking Fluoxetine for depression and an anticoagulant, a class of blood-thinning medication that requires regular lab work and observation for signs of active bleeding. The care plan laid out the requirements plainly: assess the drug treatment's effectiveness, monitor mood and response to the antidepressant, ensure pharmacy consultant review. Surveyors went looking for documentation that any of this had been done. They found none.
The absence wasn't subtle. There was no monitoring record for the anticoagulant. No monitoring record for the antidepressant. No pharmacy reviews.
A second resident, R5, came to the facility with aphasia, diabetes, and a traumatic brain injury. The surveyor found the same gap: no evidence of monthly pharmacy reviews anywhere in the medical record.
On February 27, Director of Nursing DON-B told the surveyor that pharmacy recommendation documents were not on hand at the facility and that a request had been sent to the pharmacy for additional documentation. She said she was unable to verify whether the pharmacy's recommendations had been followed up on at all.
The surveyor brought the findings directly to Nursing Home Administrator NHA-A on March 3. The concerns were specific: R34 had no documented monitoring for either the anticoagulant or the antidepressant, and neither resident had evidence of monthly pharmacy reviews. The administrator offered nothing in response. No additional information was provided by the facility at that time.
That phrase appears twice in the inspection report. Both times, it marks the end of a conversation in which the facility was confronted with a gap in basic medication oversight and said nothing.
Anticoagulants require monitoring because the margin between a therapeutic dose and a dangerous one is narrow. Too little medication and a clot can form. Too much and internal bleeding becomes a risk. The care plan for R34 spelled this out, noting the need to monitor lab work as ordered and to watch for signs of active bleeding. That language exists in a care plan because someone, at some point, recognized the stakes. The inspection found no evidence the monitoring ever followed.
Fluoxetine, the antidepressant R34 was taking, is generally considered lower-risk than anticoagulants, but the care plan still called for tracking mood and medication response. Surveyors couldn't find that documentation either.
Monthly pharmacy reviews exist precisely to catch problems like these, to flag when a medication isn't being monitored, when a dose may need adjustment, when something in the record doesn't match what's happening clinically. At Geneva Lake Manor, those reviews weren't in the building. Whether they had ever been completed, or whether anyone had read them and acted on what they said, remained unverified as of the inspection's close.
The deficiency was cited at a level of minimal harm or potential for actual harm, a designation that reflects what inspectors could document, not necessarily what occurred between visits.
R34's care plan was initiated in August 2024. By the time surveyors arrived in late February 2025, more than six months had passed. The monitoring that was supposed to happen during that time, the lab checks, the mood assessments, the pharmacy consultations, left no trace in the record.
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.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
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.
That exchange, on February 27, took place during a March 2025 inspection of the 211 South Curtis Street facility.
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.