Golden Age Manor: Infection Control Failures Found - WI
Inspectors watched the entire sequence on April 7, 2025.
The aide, identified in records as CNA F, was helping a resident referred to as R33 with incontinence care after transferring her from a wheelchair to a toilet using a sit-to-stand lift. When bowel movement got on her gloves, CNA F wiped them clean with a disposable wipe rather than removing them. She finished the care, removed the gloves without performing any hand hygiene, and then placed a clean incontinence pad on R33 and pulled up her pants with bare hands.
She transferred R33 back into her wheelchair. Removed the transfer belt. Pushed her toward the door.
Then she used hand sanitizer.
When an inspector spoke with CNA F five minutes later, the aide said she had received hand hygiene training the previous month. Asked what she should do when gloves are visibly soiled, CNA F said she was not aware they needed to be changed and could not simply be wiped clean. She said she knew hand hygiene should happen when leaving a room, but the inspector noted she had not performed it immediately after removing the soiled gloves.
Two other nurses confirmed the correct standard when interviewed separately. Licensed Practical Nurse E said her expectation was that visibly soiled gloves be removed immediately and that hand hygiene follow. Registered Nurse C said the same, and acknowledged that additional infection control and hand hygiene education would need to be provided.
The CNA's lapse was not the only infection control failure inspectors documented during the April 8 to 10 survey.
A resident identified as R1 had a urinary catheter with no active Enhanced Barrier Precautions order, a protocol used to reduce the spread of infection in catheterized residents. Inspectors observed R1 sitting in a wheelchair in their room, catheter tubing visible running out from the bottom of the right pant leg, draining clear yellow urine into a dignity bag hanging below the chair.
There was a contact precautions sign posted outside R1's room. When an inspector asked Registered Nurse I what the sign was for, the nurse said it was for R1's roommate, not for R1.
The Nursing Home Administrator, identified as NHA A, acknowledged the problem when interviewed on April 10. The administrator said R1 should have had an Enhanced Barrier Precautions order initiated when the catheter was placed, and recognized that the gap had the potential to spread infection to R1 and to other residents.
The administrator did not explain how long the order had been missing.
Urinary catheters are a well-documented infection risk in nursing home settings. Residents with catheters are vulnerable to urinary tract infections that can become bloodstream infections, and the absence of proper precaution protocols increases exposure risk for everyone in proximity, including roommates and staff.
Together, the two findings point to a pattern inspectors categorized as affecting many residents, not just the individuals directly observed. CMS rated the level of harm as minimal harm or potential for actual harm, the lower end of the deficiency scale, but the classification reflects what was caught on those specific days, not what may have occurred before surveyors arrived.
CNA F went through hand hygiene training a month before inspectors watched her wipe feces off her gloves and continue working. The training did not cover, or did not stick, on the basic rule that soiled gloves must come off.
R33 got a clean incontinence pad. She also got whatever was left on those hands.
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.
Inspectors watched the entire sequence on April 7, 2025.
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.