Golden Age Manor: Food Safety & Infection Control Fails - WI
The April incident at Golden Age Manor illustrates the infection control breakdowns federal inspectors documented during a three-day survey that found staff repeatedly violated basic hygiene protocols while caring for the facility's 60 residents.
In the kitchen, Head Cook G cleaned a food thermometer with alcohol but immediately stuck the wet probe into food items without letting it air dry, potentially contaminating meals served to residents. The same day, inspectors found unlabeled containers of sliced tomatoes, sour cream, shredded cheese, and pre-poured juice cups in the walk-in cooler with no preparation or expiration dates.
"These foods were covered and on a tray; however, nothing on the tray was labeled or dated resulting in the potential for foodborne illness to spread," inspectors wrote.
The violations extended beyond the kitchen. During personal care for a resident on enhanced barrier precautions due to antibiotic resistance, nursing assistant J removed soiled gloves after cleaning the resident's buttocks but failed to wash her hands before touching the resident to reposition them in bed.
The assistant then applied new gloves, removed them again without hand hygiene, and gave the resident a call light and bed remote with unwashed hands. When questioned, the nursing assistant acknowledged she "was not aware the gloves should be changed and not wiped clean."
Resident 9, who has multiple sclerosis and a stage 4 pressure ulcer, requires enhanced barrier precautions specifically because of resistance to multiple antibiotics. The facility's own policy mandates these precautions for residents with wounds and indwelling medical devices to prevent transmission of drug-resistant organisms.
Yet another resident with a urinary catheter had no enhanced barrier precautions order at all. Inspectors observed the catheter tubing hanging below the resident's wheelchair with clear yellow urine visible. Administrator A acknowledged the resident "should have had EBP order initiated when the urinary catheter was placed" and that the oversight "had the potential to spread infection and put R1 and other residents at risk."
The facility's infection control program showed systematic failures. Surveillance logs for COVID-19 and influenza outbreaks from February 2024 through March 2025 lacked basic information including symptom onset dates, test results, treatment details, and isolation periods.
For a February influenza outbreak, inspectors "could not find the exact start day" or "what measures were placed to prevent the spread of infection." The same gaps existed for a September COVID-19 outbreak, with no documentation of when isolation protocols began or staff education occurred.
Infection preventionist Nurse C told inspectors that Staff Specialist K, who has no medical training or nursing license, handles calls from sick employees and advises them on testing and return-to-work decisions. One staff member with fever, migraine, and vomiting at 5:30 AM returned to work less than 24 hours later at 4:30 AM.
"The staff member probably shouldn't have come back into work until over 24-hour fever free," Nurse C acknowledged.
The facility's water management program to prevent Legionella growth existed only on paper. While staff conducted "Flush Friday" activities in the vacant north wing, this practice wasn't documented in any policy. Nurse C admitted the informal flushing routine was "just something that we know to do" but couldn't identify other unoccupied rooms that might need similar treatment.
Antibiotic stewardship proved equally inadequate. Nurse C, responsible for monitoring antibiotic use, receives reports from the pharmacy roughly two weeks after residents start antibiotics. When asked about criteria for determining appropriate antibiotic selection, she responded, "I am not a doctor. I don't know."
Inspectors found she wasn't using established McGeer's or Loeb's criteria for antibiotic monitoring. "RN C indicated she does not have a process in place for monitoring correct antibiotic use for residents," the report states.
The facility also failed to offer the 2024-2025 COVID-19 vaccine to at least one resident. When questioned, infection preventionist C said she "did not think R1 needed to be approached again because she had declined in 2023," despite CDC guidelines recommending annual vaccination for high-risk populations.
Food safety violations compounded the infection risks. Dietary Manager D acknowledged that opened and prepared foods should be dated but told inspectors the unlabeled items had "potential for foodborne illness to spread." The manager disposed of potentially hazardous foods during the inspection.
Head Cook G, when observed checking food temperatures, cleaned the thermometer probe with alcohol wipes but immediately inserted it into the next food item without allowing the required air-drying time. She admitted being "unsure" when she last received temperature-checking training and was "not aware of the amount of time to allow cleaner to dry."
The facility operates with one room that measures only 96.5 square feet, below the required 100 square feet for single occupancy. Administrator A acknowledged the deficiency but said expanding the room wasn't "cost effective" given their limited private rooms.
"We always put a smaller ambulatory person in the room," the administrator explained, noting they inform residents and families about the size difference before placement.
The resident in the undersized room told inspectors she likes the space, calling it "comfy" and saying "the size fits me well." She particularly appreciated the large window where she can "see the sun."
These violations occurred despite facility policies requiring proper food labeling, hand hygiene after glove removal, and enhanced precautions for high-risk residents. Licensed Practical Nurse E told inspectors her expectations would be that "soiled gloves be removed" and "hand hygiene should be performed immediately when gloves are removed."
Nurse C acknowledged that "further infection control/hand hygiene education is required and will be provided" but the systematic nature of the violations suggests deeper problems with oversight and training at the 60-bed facility.
The inspection found violations affecting "many" residents in multiple categories, from food safety to infection control to vaccination documentation, painting a picture of an institution struggling with basic safety protocols across multiple departments.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 16, 2026 · Our methodology
GOLDEN AGE MANOR in AMERY, WI was cited for violations during a health inspection on April 10, 2025.
The violations extended beyond the kitchen.
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.
Frequently Asked Questions
- What happened at GOLDEN AGE MANOR?
- The violations extended beyond the kitchen.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in AMERY, WI, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from GOLDEN AGE MANOR or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 525507.
- Has this facility had violations before?
- To check GOLDEN AGE MANOR's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.