Golden Age Manor: Missing Hospice Care Plan - WI
The resident, identified in inspection records only as Resident 3, was started on hospice services on March 12, 2025. By April 8, when a surveyor asked Nursing Home Administrator A directly whether a hospice care plan had been developed, the administrator confirmed it had not. The inspection concluded two days later, on April 10.
Resident 3 carries a long list of diagnoses: dementia, constipation, hypertension, neuralgia, osteoarthritis of the knee, muscle weakness, spinal stenosis, pain, transient ischemic attack, anxiety, dysphagia, hemiplegia and hemiparesis, atrial fibrillation, and cognitive communication deficit. The resident scored in the severely impaired range on the Brief Interview for Mental Status, a standard cognition screening. Staff handle every activity of daily living.
That is the person who went without a hospice care plan for 27 days.
A hospice care plan is not a formality. For a resident with severe cognitive impairment who cannot speak for themselves, it is the document that tells staff what comfort looks like, what interventions to pursue, what to withhold, and how to recognize and respond to pain. Without it, care decisions exist in a gap between what hospice providers intend and what nursing home staff actually do at the bedside.
Golden Age Manor's own care plans for Resident 3 contained no hospice component and no end-of-life plan of any kind, according to the inspection report. The deficiency was cited at a level of minimal harm or potential for actual harm, affecting a small number of residents.
The administrator did not dispute the finding. There is no indication in the inspection record that staff were unaware of the enrollment date, or that the gap resulted from a miscommunication with the hospice provider. The care plan simply did not exist.
Resident 3 is dependent on staff for everything. Bathing, dressing, eating, repositioning. The resident cannot reliably communicate needs or distress. That dependency makes the care plan more important, not less, because there is no other mechanism for the resident's wishes or comfort priorities to be known and followed consistently across shifts and across staff.
Inspectors classified the violation under the regulatory category governing comprehensive care plans, a requirement that facilities develop and implement individualized plans for each resident that address their full medical and personal circumstances. Enrollment in hospice is a significant clinical event, one that shifts the goals of care from treatment toward comfort, and it requires its own documented plan.
Golden Age Manor is a nursing facility at 220 Scholl Court in Amery, a small city in Polk County in northwestern Wisconsin. The inspection was conducted April 10, 2025.
The inspection report does not say whether a care plan was created after the surveyor raised the issue on April 8. It does not describe what happened during those 27 days, whether Resident 3 experienced pain that went unaddressed, whether comfort measures were applied consistently, or whether the hospice team and nursing home staff operated from a shared understanding of the resident's goals. Those questions are not answered in the record.
What the record does say is that a person with dementia, with hemiplegia, with a history of stroke, with severe cognitive impairment, with no ability to advocate for themselves, was enrolled in hospice care and did not have a plan.
The administrator knew. The surveyor asked, and the administrator said so.
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.
The resident, identified in inspection records only as Resident 3, was started on hospice services on March 12, 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.