Golden Age Manor: Contracture Care Failures - WI
The resident, identified in inspection records as R9, has a stage 4 pressure ulcer on her sacral region, paraplegia, muscle weakness, and peripheral venous insufficiency. Her care plan, written in April 2024, directed staff to perform passive range of motion exercises on her at bedtime, ten repetitions each night, every night. The goal was to keep her from losing the ability to bend her knees and elbows entirely.
Inspectors reviewed the restorative nursing logs. The earliest records available began on March 25, 2025, with no prior documentation on file. What those logs showed was a pattern of gaps: no exercises on March 29, none on March 31, none on April 3, April 4, April 5, or April 6. On April 8, the session was skipped again. Of the 15 days captured in the records, R9 missed her ordered therapy on six of them.
On the days staff did complete the exercises, the sessions were brief. Two minutes short of the bedtime window on some nights. Six minutes on others.
R9 knew the exercises were supposed to happen. She told the inspector she has contractures in her legs and that the program is posted on her bulletin board. She likes having it done at bedtime. She just has to remind staff, every time, or it doesn't happen.
When inspectors sat down with a registered nurse identified as RN C on April 9, the conversation was direct. The nurse acknowledged there was no formal review of the restorative program. If a resident declined exercises, staff were supposed to document the refusal. But R9 had no documented refusals. The sessions were simply not completed, and not recorded as missed for any reason.
The nurse said that therapy would only be consulted if a decline was noticed. Nobody was monitoring the logs closely enough to notice the gaps.
The inspector asked a pointed question: if assessments of the program had been completed, would this problem have been caught? RN C said yes. It would have been caught.
The nurse also acknowledged that the tracking of R9's range of motion exercises had been entered incorrectly before the March 25 start date and was not tracked at all during that period. How long the program had been running without proper documentation, the records do not say. The care plan had been in place since April 2024, nearly a full year before the logs begin.
R9 requires maximum staff assistance to dress her upper body and perform personal hygiene. She is fully dependent on staff for showering, lower body dressing, moving in bed, and transfers. She has no history of refusing care. Her cognition is moderately impaired, with a scored assessment placing her in a range where she can communicate but may not always advocate effectively for herself.
She was advocating. She was asking staff, night after night, to do what her care plan already required them to do.
The deficiency was cited at a level of minimal harm or potential for actual harm, affecting a small number of residents. Inspectors noted a second resident, R3, whose exercise minutes were also reviewed, though details about that resident's specific gaps were not included in the cited findings.
Contractures, when they progress, are not reversible. Joints that lose their range of motion through disuse do not recover it through stretching that starts months later. R9's long-term goal, written into her care plan, was simply to be able to bend her knees and elbows with assistance by June 2026. Whether that goal remains achievable depends on exercises that, as of the week inspectors arrived, she was still having to request for herself.
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.
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Last verified: October 29, 2026 · Our methodology
GOLDEN AGE MANOR in AMERY, WI was cited for violations during a health inspection on April 10, 2025.
Her care plan, written in April 2024, directed staff to perform passive range of motion exercises on her at bedtime, ten repetitions each night, every night.
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.