Golden Age Manor: Pain Care Plan Missing for Opioid Patient - WI
Federal inspectors visiting the 220 Scholl Court facility on April 10, 2025 found that the care plan for the resident, identified in inspection records as Resident 35, contained no pain management component. Not in a dedicated section. Not embedded in health maintenance. Not anywhere.
Resident 35 had been admitted with bilateral primary osteoarthritis of both knees, chronic pain syndrome, unspecified hip pain, anxiety, and vascular dementia with behavioral disturbances. A January 2025 assessment rated the resident as having moderate cognitive impairment and needing substantial to total assistance with personal care and daily activities. Staff used a mechanical lift for every transfer, whether moving to a chair or to the shower.
The resident had no impairment to the upper body. The lower body was a different matter.
An opioid monitoring order had been active in the electronic medication record since December 31, 2024. The order was detailed. It listed tolerance, missed doses, increased sensitivity to pain, constipation, nausea, vomiting, dry mouth, sleepiness, dizziness, confusion, depression, itching, sweating, and respiratory depression as side effects to watch for and report to a provider. The order was open-ended, meaning it carried no expiration date.
The care plan carried none of that forward into daily practice. There were no documented approaches for staff to follow when the resident's pain increased. No guidance on what "on time" meant for medication delivery. No instructions for what to do when movement, the resident's identified pain trigger, became unavoidable during transfers or bathing.
On the morning of April 8, an inspector found Resident 35 sitting alone in the dining room and asked about pain. The resident said there was none at the moment. Then came the qualifier: movement hurts the most. As long as the medication arrives on time, the resident said, the pain usually stays under control. There were other medications available for when it didn't.
That exchange described a pain management system that existed in the resident's experience of daily life and in a medication order. It did not exist on paper in any form the care team was required to follow or update.
Care plans in a nursing home are not administrative paperwork. They are the document that tells every nurse, aide, and therapist on every shift what a resident needs and how to provide it. When a resident's condition changes, the care plan is what gets updated. When a new staff member takes over, the care plan is what they read. When a resident with moderate cognitive impairment cannot fully advocate for themselves in the moment, the care plan is what speaks for them.
For Resident 35, that document was silent on pain.
The inspection cited the deficiency at a level of minimal harm or potential for actual harm, meaning inspectors did not find evidence that the gap had yet caused a serious injury. The violation affected some residents, not just one.
What the record shows is a resident managing a complex, chronic pain condition with opioids, dependent on staff for every transfer, who told an inspector that timing was the difference between a tolerable day and one that wasn't. Behind that resident, on every shift, was a care plan that offered no direction on how to make sure timing held.
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.
Not embedded in health maintenance.
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.