Golden Age Manor: MDS Assessment Missed for Hospice Resident - WI
That is what a federal inspection completed March 30, 2026 found at the 220 Scholl Court facility in this small city in western Wisconsin, about an hour east of Minneapolis.
The assessment in question is called a Significant Change in Status Assessment, a standardized federal form that nursing homes use to document and track major shifts in a resident's condition. Entering hospice qualifies as one of those shifts. The assessment is supposed to capture where a resident stands across multiple areas of care at the moment their trajectory changes, creating a record that shapes how staff plan and deliver care going forward.
At Golden Age Manor, someone opened the assessment after the resident, identified in inspection records only as R1, entered hospice. Then it sat there, incomplete, never submitted. R1 died before anyone closed it out.
The Director of Nursing, identified in the inspection report as DON B, confirmed all of this to the inspector during an interview at 2:50 p.m. on the day of the survey. DON B explained that the facility completes assessments upon admission, annually, quarterly, with significant changes, and as needed. DON B said the facility follows federal guidelines, and described exactly what a significant change means: a decline or improvement across two or more areas of care, or when a resident is admitted to or removed from hospice. DON B put the completion window at 14 or 15 days from the time the change is recognized.
Then DON B acknowledged that R1's assessment had not been completed and was past the 14-day mark.
The inspection report classifies the violation at the lowest level of harm, noting minimal harm or potential for actual harm. It affected few residents. By the numerical logic of federal nursing home oversight, this is a minor finding.
But the resident was dying. The assessment existed to document their condition and guide their care at the most vulnerable point of their life. Someone opened it, and no one came back.
The facility's own policy, titled Comprehensive Assessments and last revised before the inspection, states that assessments are conducted according to the criteria and timeframes in the federal Resident Assessment Instrument User's Manual. That manual sets the 14-day deadline explicitly. Golden Age Manor's last completed assessment for R1 predated the hospice admission. The significant change assessment was started after the hospice admission and never submitted. R1 expired.
There is nothing in the inspection record to indicate that the incomplete assessment caused a specific clinical failure. The inspector did not find that R1 was denied a medication, missed a therapy session, or suffered a wound from a lapse in repositioning. The harm level reflects that uncertainty. What the record does show is that a process designed to ensure a dying person's care was formally reviewed and documented at a critical moment did not happen, and no one caught it until a federal surveyor pulled the file.
DON B did not dispute any of it. The acknowledgment was immediate and direct: the assessment was incomplete, the deadline had passed.
Golden Age Manor is a small facility. Amery is a city of fewer than 3,000 people. The nursing home sits on Scholl Court, a short road off the main commercial corridor. For many residents, it is the last place they will live.
R1 was one of them.
The inspection report does not say how long R1 was in hospice before dying, or how far past the 14-day window the assessment sat before the surveyor arrived. The dates have been redacted to protect confidentiality. What remains is the outline: a resident entered hospice, a required assessment was opened and abandoned, and the resident died with the assessment still sitting unfinished in the electronic health record.
For information on the facility's plan to correct the deficiency, CMS directs the public to contact Golden Age Manor or the Wisconsin state survey agency directly.
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
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 17, 2026 · Our methodology
GOLDEN AGE MANOR in AMERY, WI was cited for violations during a health inspection on March 30, 2026.
Entering hospice qualifies as one of those shifts.
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.
Frequently Asked Questions
- What happened at GOLDEN AGE MANOR?
- Entering hospice qualifies as one of those shifts.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in AMERY, WI, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from GOLDEN AGE MANOR or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 525507.
- Has this facility had violations before?
- To check GOLDEN AGE MANOR's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.