Golden Age Manor: Antibiotic Oversight Failures - WI
Federal inspectors visited the 60-bed facility on April 10, 2025, and what they found in the infection prevention program wasn't a program with gaps. It was, in most meaningful ways, not a program at all.
The facility's own policy named the Infection Preventionist as the person responsible for monitoring antibiotic use, tracking infection rates, and ensuring unnecessary antibiotics weren't being prescribed. That person was Registered Nurse C. When the surveyor sat down with RN C and started asking basic questions about how that work was being done, the answers were striking.
The surveyor asked how RN C tracked infections, what antibiotics residents were placed on, and how RN C knew whether the correct antibiotic was being used. RN C asked what the surveyor meant. The surveyor asked what criteria RN C used to determine whether an antibiotic was needed in the first place. RN C indicated she was unsure what the surveyor was talking about.
"I am not a doctor. I don't know," RN C told the surveyor.
RN C's system for monitoring antibiotic use consisted of a monthly printout from a service called Health Direct, listing which residents had been on antibiotics that month. The report arrived roughly two weeks after residents had already been started on the drugs. That was when RN C reviewed antibiotic use. Not before. Not in real time. After the fact, and late.
The surveyor asked about McGeer's criteria and Loeb's criteria, two widely used clinical frameworks for determining when an infection diagnosis is appropriate and whether antibiotic treatment is warranted in long-term care settings. RN C indicated she was not using either. The surveyor referred her to CDC guidelines and both frameworks. RN C said she would start using them.
The inspection logs told the same story. Surveyors reviewed infection surveillance records covering February 2024 through March 2025, more than a year of documentation, and found the same information missing across every entry: no symptom onset dates, no culture or test results, no record of which antibiotics were chosen or when they started and stopped, no resolution dates. The line lists that are supposed to give an infection preventionist the data needed to spot patterns, catch inappropriate prescribing, and protect residents from drug-resistant bacteria were incomplete across the board.
Antibiotic stewardship exists for a specific reason. Antibiotics given when they aren't needed, or the wrong antibiotic chosen for a given infection, contribute to the development of drug-resistant organisms. In a nursing home, where residents are older, often immunocompromised, and living in close proximity, that risk is not theoretical. Infections caused by resistant bacteria are harder to treat and more likely to be fatal.
The facility's policy acknowledged all of this. It called for quarterly review of infection data with the interdisciplinary team and medical director. It assigned the Infection Preventionist clear responsibility. On paper, the program existed. In practice, the nurse holding that title had no process for monitoring whether residents were on the correct antibiotics, had never applied the clinical criteria her role required, and learned about antibiotic use weeks after decisions had already been made.
Sixty residents were identified as potentially affected.
RN C, by the end of the interview, had been introduced to the McGeer's and Loeb's criteria for the first time. She told the surveyor she would begin using them. The surveillance logs covering the prior fourteen months remained what they were.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Golden Age Manor from 2025-04-10 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: October 28, 2026 · Our methodology
GOLDEN AGE MANOR in AMERY, WI was cited for violations during a health inspection on April 10, 2025.
Federal inspectors visited the 60-bed facility on April 10, 2025, and what they found in the infection prevention program wasn't a program with gaps.
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.