Golden Age Manor: Medication Documentation Failure - WI
The inspection took place April 9 and 10, 2025. A surveyor was watching at 7:24 in the morning when Licensed Practical Nurse H gave the calcitonin nasal spray to Resident 19, who lives at the facility with a diagnosis of allergic rhinitis. The medication order was specific: one spray into one nostril, once daily, alternating nostrils each day. The alternating instruction matters because it is built into the dosing. Without a record of which side was used the day before, the next nurse to give the medication has no way to know where to spray.
LPN H administered the dose into the right nostril, then documented that the medication had been given. She did not record which nostril.
Fourteen minutes later, the surveyor asked her about it. LPN H said staff used to document the nostril, but that practice had stopped at some point. She said she works with Resident 19 every day and knows which nostril to use.
That explanation has a straightforward problem. LPN H is not the only person who will ever give Resident 19 that medication. On any day she is not working, a different nurse picks up where the documentation leaves off — or, without documentation, starts from nothing.
The Director of Nursing, identified in the report as DON B, said the next morning that nursing staff are expected to document the location of a medication administration to ensure accuracy. DON B said she was unaware this was not being done.
That gap — between what the Director of Nursing believed was happening and what the surveyor actually watched — is the core of what inspectors cited. The facility's own policy, revised in April 2019, lists the route of administration and the injection or application site as required elements of any medication record. For a nasal spray with an alternating-nostril order, the site is the nostril. It was not recorded.
The violation was classified as causing minimal harm or potential for actual harm, and it affected a small number of residents. The inspection report reviewed two residents on this question and found the documentation failure in one of them.
One resident, one medication, one missing data point. The inspection report does not describe any instance where the documentation gap caused a visible problem for Resident 19. What it describes is a system that stopped working at some point — LPN H's phrase was "a while ago" — without anyone in a supervisory role catching it.
The calcitonin nasal spray is typically prescribed for bone density or, in some formulations, nasal congestion associated with allergic rhinitis. Alternating nostrils is standard practice to reduce local irritation and ensure consistent absorption. Whether Resident 19 received the spray in the correct nostril on any given day, before the surveyor arrived, is not something the facility's records can now answer.
LPN H, by her own account, carries that information in her memory. She works every day. She knows. But the records that are supposed to outlast any single nurse's shift, and any single nurse's memory, do not reflect it.
DON B said she was unaware. The policy said document it. For some stretch of time measured in the nurse's words as "a while," nobody did.
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 30, 2026 · Our methodology
GOLDEN AGE MANOR in AMERY, WI was cited for violations during a health inspection on April 10, 2025.
The inspection took place April 9 and 10, 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.