Geneva Lake Manor: Medication Errors Found in Inspection - WI
The inspection, conducted in March 2025, focused on a single resident identified in records as R13. The resident was prescribed Amantadine HCl, a medication taken once daily. On March 3, nurses documented the drug as "drug/item unavailable" and did not administer it. The medication had been delivered. It was already in the building.
When a surveyor raised the missed doses with the Assistant Director of Nursing that afternoon, the ADON said she would look into it. About 35 minutes later, she came back with an answer: the Amantadine HCl had been delivered and placed in overflow storage. The nurses had not looked there. The ADON moved the medication to the medication cart herself.
The ADON also confirmed that Amantadine HCl was not stocked in the facility's contingency supply, meaning there was no backup available if the primary supply ran short.
By that point, the dose had already been missed. The ADON contacted the nurse practitioner to ask whether it was acceptable to give the medication late. An order was entered later that day for a one-time dose to be administered between 3:00 PM and 11:00 PM.
The following morning, the Director of Nursing told the surveyor that the decision had been made to contact the doctor, update them on what had happened, and get an order to give the late dose, given that it was a once-daily medication.
That same afternoon, the surveyor spoke with two nurses separately. The first was an agency licensed practical nurse, identified as LPN-T, who had worked the morning shift on March 3 and left before the issue was resolved. She said she did not remember the medication. The second nurse, LPN-Q, was the one who ultimately gave the one-time makeup dose on March 3. She told the surveyor she had to call the pharmacy and ask them to resend the order before she could administer it.
The inspection report notes that no further information was provided explaining why the facility failed to ensure R13 received the medication without error.
The resident was described as needing to be "vigilant" and watch each medication being given, a detail that signals a level of cognitive or medical complexity that makes accurate administration more, not less, critical.
The violation was cited at a level of minimal harm or potential for actual harm, affecting a small number of residents.
What the inspection leaves unresolved is how long this kind of gap could persist before someone noticed. The medication was in the building. The nurses working that shift did not find it. One of them, an agency employee with no long-term familiarity with the facility's storage systems, said she didn't remember the drug at all. The fix, when it came, required the ADON to physically move the medication from one location to another and a nurse to call the pharmacy to get the order resent.
R13 went without a prescribed daily medication while the facility sorted out where it had been placed.
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.
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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.
The inspection, conducted in March 2025, focused on a single resident identified in records as R13.
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.