Golden Age Manor: COVID Vaccine Records Missing - WI
That was her explanation. That was all she had.
The resident, identified in inspection records only as R1, carries a diagnosis list that reads like a catalog of COVID risk factors: Alzheimer's disease, dementia, chronic kidney disease stage 3b, polyneuropathy, edema, depression, anxiety disorder, bipolar disorder, tremor, urinary tract infection, and insomnia. The CDC's own guidance singles out adults 65 and older and people at high risk for severe COVID as the groups for whom the 2024-2025 vaccine is especially important.
There was no consent form for R1. No declination form. No screening documentation. Nothing in the electronic medical record. Nothing in the paper copies the infection preventionist pulled together on the morning of April 10, 2025, when a surveyor came asking.
The infection preventionist, identified in the report as IP C, described her standard process to the surveyor just before 8 a.m. that morning. If a resident has a power of attorney, she sends the POA a letter with education and a consent form, then follows up with questions. If the resident manages their own affairs, she educates them directly and collects consent. She told the surveyor she would pull all influenza, pneumonia, and COVID consents and declinations for the 2024-2025 vaccination year.
Just before 9 a.m., she handed over what she had found. R1's COVID paperwork was not in the stack.
When the surveyor asked about it, IP C said she did not think R1 needed to be approached again because the resident had declined in 2023.
A 2023 declination is not a permanent record. Vaccine recommendations are issued annually. A resident's medical condition, their willingness to consent, and the composition of the vaccine itself can all change from one year to the next. The process IP C described to the surveyor — education, consent, follow-up — is precisely what did not happen for R1 in 2024 or 2025.
By late morning, IP C checked with the facility's pharmacy for any additional documentation. There was nothing more.
The facility's own vaccination policy made the gap worse, not better. The only policy produced when the surveyor requested documentation was one titled Influenza and Pneumococcal Vaccinations, dated March 2022. It does not mention COVID-19 at all. The surveyor asked twice for a COVID-specific policy. None was provided.
The deficiency was cited at minimal harm, meaning inspectors found no documented injury to R1 as a result of the missed screening. That classification reflects what inspectors could confirm, not what the gap in documentation made impossible to know.
What the record does show is a resident with Alzheimer's and dementia, conditions that affect a person's ability to advocate for their own medical care, who went through an entire vaccination year without anyone at Golden Age Manor sitting down with her, or with whoever holds her power of attorney, to ask whether she wanted protection against a virus that kills older, medically complex adults at rates far higher than the general population.
IP C's reasoning, that a prior declination absolved the facility of any further obligation, was the whole of the facility's answer.
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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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.
There was no consent form for R1.
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.