Golden Age Manor: Fall From Ignored Care Plan - WI

The Director of Nursing at Golden Age Manor acknowledged it directly to a federal surveyor on March 30, 2026. CNA H had been working alone during R4's transfer. CNA H was not following the care plan. The Director of Nursing, identified in inspection records as DON B, said both things plainly, in sequence, without apparent dispute.

What DON B did not say was that anyone had been sent home. Under the facility's own stated protocol, that was one option when a fall resulted from a staff member ignoring a care plan and the injury was severe. DON B noted that sending someone home depended on severity of injury, and that if it would cause a staffing concern, the staff member in question would instead be required to work with a partner going forward. The calculus, in other words, involved the facility's scheduling needs as much as the resident's outcome.

R4's fall was the reason the surveyor was there at all. The inspection, conducted on March 30, 2026, was a complaint investigation, not a routine survey. Someone had reported what happened to state authorities.

The sit-to-stand lift is not a piece of equipment that signals danger on its own. It exists specifically to help residents who have some weight-bearing capacity but cannot complete a transfer independently. CNA D, another nursing assistant at the facility, explained to the surveyor how the system is supposed to work: transfer requirements for each resident are documented in the care plan, accessible through the facility's computer system. Hoyer lifts, which bear the full weight of a non-weight-bearing resident, always require two staff. Sit-to-stand lifts can require one or two, depending on what the care plan specifies. For R4, the care plan specified two.

CNA D said something else worth noting. CNA D had never been in a situation that required completing a two-person lift alone. But CNA D had waited, sometimes for a while, for a second staff member to become available. That detail sits in the inspection record without elaboration. It suggests that the staffing conditions that might pressure a CNA into proceeding alone were not unfamiliar at Golden Age Manor, even if CNA D had personally always waited.

CNA H did not wait.

RN F, the nurse whose fall response protocol the surveyor documented that same afternoon, described a careful, step-by-step process for what happens after a resident hits the floor: immediate assessment, vitals, a call to 911 if warranted, an event assessment, neurological checks if the fall was unwitnessed or involved a head impact, and interviews with CNAs. RN F also mentioned re-education as an initial response when staff were involved.

DON B's description of the expected response was largely the same, with more institutional detail. Interviews with the resident and staff. Immediate interventions while the Interdisciplinary Team investigated further. Re-education if the fall came from a staff member not following a care plan. And then the conditional consequences: possible removal from duty, or a required partner, depending on injury severity and whether the facility could absorb the staffing loss.

The inspection report does not describe R4's injuries. It does not say whether 911 was called, whether neurological checks were performed, or what the event assessment found. The surveyor's record captures the facility's stated procedures and the Director of Nursing's acknowledgment of what went wrong. What the report does not contain is any account of what R4 experienced on the floor, or afterward.

The violation was cited at a level of minimal harm or potential for actual harm, the lowest tier in the federal harm scale. That classification reflects the regulatory determination of what occurred, not a judgment about what could have happened when a resident who required two people to move safely was moved by one.

CNA D's account of sometimes waiting a while for a second staff member to arrive is the quiet center of this inspection record. It describes a workplace where the correct procedure is known, where CNAs understand what the care plan requires, and where the gap between that requirement and available staffing is something workers navigate by waiting. Most of the time, the waiting works. On the day of R4's fall, someone decided not to wait, or felt they couldn't, or made a calculation that the surveyor's report does not explain and the facility's leadership did not dispute.

DON B acknowledged CNA H was working alone. DON B acknowledged CNA H was not following the care plan. Those two facts were offered to the surveyor without evident resistance, as though they were simply the known facts of what had happened. Whether CNA H was re-educated, sent home, or assigned a mandatory partner after the fall, the inspection record does not say.

What it does say is that another CNA at the same facility, asked on the same afternoon how they know what a resident's transfer requires, described a system that depends entirely on staff choosing to look at the care plan and then choosing to follow it. The computer is there. The care plan is there. The requirement for two staff was there, documented, for R4.

CNA H knew, or should have known, and transferred R4 alone anyway.

R4 fell.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Golden Age Manor from 2026-03-30 including all violations, facility responses, and corrective action plans.

Additional Resources

• View all inspection reports for Golden Age Manor
• Browse all WI nursing home inspections