Golden Age Manor: Sleep Medication Without Monitoring - WI
The resident, identified in inspection records only as R9, carries a medical history that reads as a portrait of profound physical dependency. Multiple sclerosis. Paraplegia. A stage 4 pressure ulcer on the sacral region. Acute right heart failure. Pulmonary hypertension. A colostomy. R9 requires maximum staff assistance for upper body dressing and personal hygiene, and is fully dependent on staff for showering, lower body dressing, bed mobility, and transfers. A quarterly cognitive assessment placed R9 in the moderately impaired range, scoring 11 out of 15.
Since February 10, 2025, R9 had a physician order for melatonin, 5 milligrams, to be given between midnight and 3 a.m. on an as-needed basis for insomnia.
Nobody had built a care plan around that prescription. Nobody was systematically tracking when R9 slept or didn't sleep. There was no record of staff documenting overnight observations that would tell a physician whether the medication was helping, whether the dose was right, or whether it was needed at all.
When the surveyor sat down with Director of Nursing B on April 9, the questions were direct. How are you accurately collecting data to support the need for the sleep medication? Are the staff being interviewed the same ones working nights, the ones who would actually know whether R9 was awake at 2 a.m.? Are staff documenting when residents are asleep or awake?
DON B said she understood the need to collect data to support medication use. She confirmed there was no complete assessment. She confirmed there was no care plan.
The surveyor also asked whether anyone had developed a care plan with non-pharmacological interventions to promote sleep. Things like consistent bedtime routines, positioning adjustments, noise reduction, light management. For a resident with R9's level of physical limitation, those options would require staff coordination to implement, but they represent a standard first consideration before a standing medication order.
There was no such plan.
What the facility described as its sleep monitoring process was a quarterly interview, in which someone would ask staff what a resident's normal sleep pattern was. DON B did not indicate whether those interviews captured night shift staff specifically, the people most likely to observe whether a resident was awake at 1 a.m. The surveyor pressed on exactly that gap.
The inspection cited the deficiency as causing minimal harm or potential for actual harm, affecting a few residents. In the hierarchy of nursing home violations, that places it below the most severe findings. But for R9, a person who cannot reposition independently, who has an open stage 4 wound on the sacral region, who depends on staff for every transfer and every hygiene task, the absence of any sleep monitoring carries a particular weight. Sleep disruption in a resident with that degree of physical vulnerability and cognitive impairment is not a minor inconvenience. It is a clinical variable that intersects with wound healing, pain perception, and the capacity to participate in whatever rehabilitation or maintenance care is still possible.
The melatonin order had been in place since at least February. The inspection was conducted April 10. That is at minimum two months of a PRN medication administered in the middle of the night, with no structured record of when it was given, whether R9 slept afterward, or whether the underlying insomnia was improving, worsening, or unchanged.
R9 has no behaviors of rejecting care from staff, the inspection record notes. Whatever was happening in those overnight hours, R9 was not in a position to refuse the medication, demand a different approach, or flag the absence of a plan.
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 R9, carries a medical history that reads as a portrait of profound physical dependency.
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.