Golden Age Manor

F-F801 483.60 (a) (2) (i) .(C) Has similar national certification for food service management and safety from a national certifying body.

Surveyor investigated the certification further and informed NHA A the certificate provided does not meet requirements for Certified Dietary Manager.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 41 525507 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525507 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Golden Age Manor 220 Scholl CT Amery, WI 54001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 51095

Residents Affected - Many Based on observation, interview and record review, the facility did not ensure the safety of food handling in accordance with professional standards for food service safety. The facility practices had the potential to affect all 60 residents.

Foods stored in the walk-in-cooler were not labeled and dated and the Head [NAME] did not allow the thermometer probe to air dry after cleaning with isopropyl alcohol prior to inserting into foods items intended to be served to residents for lunch.

This is evidenced by:

The facility policies titled, Food Receiving and Storage revised December 2008, states in part, 7. All foods stored in the refrigerator or freezer will be covered, labeled and dates (use by date).

The Food and Drug Administration (FDA) Food Code states in part, 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface SANITIZING solutions), before contact with food.

On 4/07/25 at 9:10 AM, during initial tour of the kitchen with Dietary Manager (DM) D, Surveyor observed several opened foods in the walk-in-cooler had been opened but were not labeled with an opened date or use by date. These foods included sliced tomatoes, repackaged sour creams, opened bag of shredded cheese, a tray of individually portioned salads (coleslaw, potato salad, Jello salads) and pre-poured juice in cups. These foods were covered and on a tray; however, nothing on the tray was labeled or dated resulting

in the potential for foodborne illness to spread.

During this initial tour, Surveyor interviewed DM D, who reported the expectation would be that opened and/or prepared foods would be dated with an opened or prepared on date or a use by date. DM D did remove potentially hazardous foods and dispose of them.

On 4/08/25 at 11:17 AM, Surveyor observed Head [NAME] G take temperature of foods to be served. During checking temperature of the foods, Head [NAME] G would stick probe into isopropyl alcohol probe wipe packet, rub probe end and immediately stick in next food item without waiting to let air dry as directed. This was done with 5 of the 9 foods that were checked during observation.

On 4/08/25 at 11:44 AM, Surveyor interviewed Head [NAME] G, who reported she was trained on checking temperatures of foods a long time ago. Head [NAME] G reported she was unsure of when that would have been. Head [NAME] G reported she was not aware of the amount of time to allow cleaner to dry or that probe needs to dry and acknowledged she does not allow probe cleaning wipe to dry before checking temperature between foods.

On 4/09/25, Surveyor informed Nursing Home Administrator A of the deficiencies in food preparation and storage that were observed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 41 525507 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525507 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Golden Age Manor 220 Scholl CT Amery, WI 54001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48793 potential for actual harm Based on observation, interview and record review, the facility did not establish and maintain an infection Residents Affected - Many prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

-The facility did not a have a clear water management process or plan in effect to prevent transmission of Legionella infection. This has potential to effect 60 of 60 residents reviewed.

-The facility did not have a tracking program in place for the early detection of infected and exposed residents (R) and staff for COVID-19 and Norovirus during an outbreak.

-Resident R9 is on enhanced barrier precautions and staff did not perform proper hand hygiene practices during personal cares.

-Resident R1 has an indwelling catheter and was not on EBP

-Staff did not perform proper hand hygiene during personal cares for Resident R33.

This is evidenced by the following:

Example 1

Surveyor reviewed the facility policy titled, Water Management Program to Reduce Legionella Growth and Spread, dated last reviewed in September 2017. The policy did not have control measures for the building water system to prevent the spread of legionella described in the policy or on the flow diagram, addressing unoccupied rooms and the vacant North wing to decrease the spread of opportunistic waterborne pathogens.

On 04/10/25 at 10:39 AM, Surveyor interviewed infection preventionist, Registered Nurse (RN) C, and asked who oversees the water management program. RN C indicated that RN C, Nursing Home Administrator A, and Maintenance work together to complete water management. Surveyor asked if RN C had control points and any corrective actions to address stagnation and decrease spread of Legionella for the unoccupied rooms and vacant north wing.

RN C indicated that everyone completes flushes on Fridays for the vacant north wing but didn't know any other unoccupied rooms need to be flushed as well. Surveyor asked where that description of flushing on Fridays is occurring. RN C indicated that Flush Friday is just something that we know to do but it is not described in the facility water management policy. RN C indicated that RN C would update the water management policy to show control points and corrective actions needed when flushing vacant north wing and any unoccupied rooms in the facility.

Example 2

Surveyor reviewed infection surveillance logs dated from February 2024-present. Surveyor found missing documentation on all line lists for surveillance to include complete:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 41 525507 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525507 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Golden Age Manor 220 Scholl CT Amery, WI 54001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 -Symptoms onset date.

Level of Harm - Minimal harm or -Location/last worked. potential for actual harm -Culture/test type and result. Residents Affected - Many -Treatment parameters.

-Isolation type/date start and end.

-Resolution date and times for infections.

Surveyor reviewed facility Influenza outbreak dated sometime in February. Surveyor could not find the exact start day of Influenza outbreak and what measures were placed to prevent the spread of infection. Surveyor could not find last worked dates for staff members that became infected and worked in the facility to decrease the spread of infection. Surveyor found missing documentation on all line lists for surveillance to include complete:

-Culture/test type and result.

-Treatment parameters.

-Isolation type/date start and end.

In Influenza outbreak summary, Surveyor could not find when isolation and proper PPE usage was underway, any audits of hand hygiene, proper PPE usage, or any education to staff to decrease the spread of Influenza.

Surveyor reviewed facility COVID-19 outbreak dated sometime in September. Surveyor could not find the exact start day of COVID-19 outbreak and what measures were placed to prevent the spread of infection. Surveyor could not find last worked dates for staff members that became infected and worked in the facility to decrease the spread of infection. Surveyor found missing documentation on all line lists for surveillance to include complete:

-Culture/test type and result.

-Treatment parameters.

-Isolation type/date start and end.

-Return to work dates.

In COVID-19 outbreak summary, Surveyor could not find when isolation and proper PPE usage was underway, any audits of hand hygiene, proper PPE usage, or any education to staff to decrease the spread of Influenza.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 41 525507 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525507 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Golden Age Manor 220 Scholl CT Amery, WI 54001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 04/10/25 at 10:39 AM, Surveyor interviewed RN C after reviewing facility's IC surveillance lists and asked RN C what is RN C's process for managing and decreasing the spread of infection. RN C indicated that she Level of Harm - Minimal harm or follows the CDC guidelines and keeps track of infections monthly. Surveyor asked RN C what the process is potential for actual harm and expectations for sick employees. RN C indicated that the expectation is for staff to stay home and call staffing recruiter if symptomatic. Staff Specialist K will take sick calls and make referrals to staff on what staff Residents Affected - Many should do as far as testing goes and when to return to work. Surveyor asked RN C if Staff Specialist K has training on consulting with staff about their sickness and actions to take going forward. RN C indicated that everyone is trained at the onboarding orientation on staying home when sick. RN C indicated that Staff Specialist K does not hold a CNA license or Nurse license and is not medically trained.

Surveyor asked RN C to provide Surveyor with Staff Specialist K's training pertaining to how to consult with and make corrective actions for staff when sick. RN C indicated that RN C does not have any formal training that has been completed for Staff Specialist K. RN C indicated that before staff can return to work the staff member brings a form physically into the building and has charge nurse review the form to decide if sick employee is ok to return.

RN C reviewed online spreadsheet with Surveyor in which Surveyor observed a staff member who had fever, migraine, and vomiting on 03/09/25 at 5:30 AM, and the staff member returned to work on 03/10/25 at 4:30 AM. RN C indicated that the staff member probably shouldn't have come back into work until over 24-hour fever free. Surveyor asked RN C to provide the spreadsheet to Surveyor to document the facility's process.

In review of spreadsheet Surveyor asked RN C how RN C keeps track of what tests are performed to minimize the spread of infection. RN C indicated that Staff Specialist K has the COVID-19 test available to staff to test if symptomatic, but RN C does not have any other tests in place such as influenza or RSV. Surveyor asked RN C if RN C suggests staff members go get tested for anything else. RN C indicated that it is up to staff members if they want to see a doctor or not and get tested for other things.

Surveyor asked RN C how RN C keeps track of testing on spreadsheet, resolution date, what precautions or isolation needed, and location of where employees had worked if staff were working sick while on shift. RN C indicated that RN C is not tracking location of employees worked unless an outbreak, resolution dates were not updated on spreadsheet accurately, and testing for infections is not being offered or suggested unless COVID-19. Surveyor asked RN C if RN C thought it was appropriate that staff needed to bring in their form and physically walk into building without properly making sure the staff member was still not currently sick. RN C indicated that RN C's line lists are not as thorough as they should be, and knows the process needs to be fixed as it is not decreasing the spread of infection.

31086

Example 3

Facility policy titled, Enhanced Barrier Precautions, dated 05/01/24, states in part: It is the policy of this facility to implement enhanced barrier precautions for the preventions of transmission of multidrug-resistant organisms .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 41 525507 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525507 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Golden Age Manor 220 Scholl CT Amery, WI 54001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 2. Initiation of Enhanced Barrier Precautions:

Level of Harm - Minimal harm or b. An order for enhanced barrier precautions will be initiated for residents with any of the following: potential for actual harm 1. Wounds and/or indwelling medical devices (e.g., central lines, urinary catheters .) even if the resident is Residents Affected - Many not known to be infected or colonized with a MDRO.

The facility policy titled, Handwashing/Hand Hygiene revised October 2023 states in part, Indications for Hand Hygiene . c. after contact with blood, body fluids, or contaminated surfaces; d. after touching a resident; e. after touching a resident's environment; f. before moving from work on soiled body site to a clean body site on the same resident; and g. immediately after glove removal.

Resident R9 was admitted on [DATE REDACTED]. Resident R9's current diagnoses include multiple sclerosis, resistance to multiple antibiotics, dysphagia, acute right heart failure, pulmonary hypertension, neuralgia and neuritis, insomnia, vitamin D deficiency, myalgia, pain, hypertension, paraplegia, pressure ulcer of sacral region stage 4, colostomy, muscle weakness, and peripheral venous insufficiency.

MDS dated [DATE REDACTED], a quarterly assessment documented BIMS score of 11/15, meaning Resident R9 has moderately impaired cognition. Resident R9 has impairment to 1 side upper extremity and both sides of lower extremity. Resident R9 requires maximum staff assistance for upper body dressing and personal hygiene. Resident R9 is dependent on staff assistance for showering, lower body dressing, bed mobility and transfers. Resident R9 has no behaviors of rejecting cares from staff.

On 04/09/25 at 10:34 AM, Survey observed cares being provided by Certified Nursing Assistant (CNA) J. Resident R9 has a sign on the outside of room door for enhanced barrier precautions. CNA J sanitized hands and applied gloves and gown. CNA J completed Resident R9's upper body and peri care appropriately. After cleansing buttocks and applying barrier cream, CNA J removed gloves and did not complete hand hygiene. CNA J touched Resident R9 to position in bed. CNA J did not complete hand hygiene and applied clean gloves. Then CNA J rolled resident, finished putting on brief, pulled pants up and applied the Hoyer sling. CNA J removed gloves, did not perform hand hygiene and applied clean gloves. CNA J applied heel protective boots to Resident R9's feet. CNA J, with same gloved hands, touched the soiled plastic linen bags on the floor to move out of the way. With the contaminated gloves, CNA J placed a pillow between Resident R9's legs. CNA J removed gloves, and without hand hygiene, gave Resident R9 the call light and bed remote. CNA J removed gown and did not perform hand hygiene. CNA J moved Resident R9's overbed tray table next to Resident R9's bed. CNA J went to the bathroom, washed hands and with clean hands turned the faucet off. CNA J gathered garbage and the soiled linen bag and brought to the soiled utility room.

On 04/09/25 at 10:56 AM, Surveyor interviewed CNA J about proper hand hygiene technique and glove use. CNA J indicated hand hygiene was not completed after removing soiled gloves. Surveyor asked what the proper technique for handwashing is when turning the faucet off. CNA J indicated she turned the faucet off with her clean hands but should have used a paper towel.

On 04/09/25 at 2:31 PM, Surveyor interviewed RN C about hand hygiene and the observation with CNA J. RN C indicated staff have been trained and yesterday RN C reviewed with CNA J of proper hand hygiene practices.

49353

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 41 525507 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525507 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Golden Age Manor 220 Scholl CT Amery, WI 54001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Example 4

Level of Harm - Minimal harm or Resident R1 was admitted to the facility on [DATE REDACTED] with pertinent diagnoses of chronic kidney disease stage, edema, potential for actual harm and urinary tract infection.

Residents Affected - Many Review of Resident R1's care plan identified no urinary catheter care plan in place to prevent the spread of infection.

Review of Resident R1's orders noted:

04/04/25 Foley Catheter for Urinary Retention.

Of note: no order for enhanced barrier precautions (EBP) was noted.

On 04/08/25 at 11:58 AM, Surveyor observed a transmission sign outside of Resident R1's room stating, Contact Precautions. A personal protective equipment (PPE) cart was observed outside of room. No other precaution sign was noted. Resident R1 was observed sitting in wheelchair in room. Resident R1 had a urinary catheter hanging below wheelchair inside a dignity bag. Surveyor observed urinary catheter tubing exiting the bottom of Resident R1's right pant leg with clear yellow urine.

On 04/08/25 at 12:04 PM, Surveyor asked Registered Nurse (RN) I what the contact precaution sign outside of Resident R1's room was for. RN I stated that it was for Resident R1's roommate.

On 04/10/25 at 10:24 AM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding observation. NHA A stated that Resident R1 should have had EBP order initiated when the urinary catheter was placed. NHA A stated recognition that this had the potential to spread infection and put Resident R1 and other residents at risk.

51095

Example 5

On 4/07/25 at 10:46 AM, Surveyor observed CNA F use sit to stand to transfer Resident R33 from a wheelchair to the toilet. Resident R33 remained on the toilet.

On 4/07/25 at 10:56 AM, CNA F put on gloves and provided incontinence care for Resident R33. CNA F wiped liquid stool from resident buttocks and perineal area. After getting bowel movement (BM) on gloves, CNA F used a disposable wipe to clean off her gloves. CNA F continued to provide incontinence cares for Resident R33 without changing her gloves. After cleaning the BM, CNA F removed the gloves, did not practice any form of hand hygiene, and without donning new gloves put Resident R33's clean incontinence pad on and pulled up her pants. CNA F then moved sit to stand lift, transferred Resident R33 into her wheelchair, and removed Resident R33's transfer belt for stand lift. CNA F continued without gloves to push Resident R33 in the wheelchair to door before CNA F stopped and used hand sanitizer.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 41 525507 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525507 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Golden Age Manor 220 Scholl CT Amery, WI 54001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 4/07/25 at 11:01 AM, Surveyor interviewed CNA F who reported she had hand hygiene training last month. When Surveyor asked CNA F what should be done when there are visibly soiled gloves, CNA F Level of Harm - Minimal harm or reported she was not aware the gloves should be changed and not wiped cleaned. CNA F reported she is potential for actual harm aware that she should use hand hygiene when leaving room. Surveyor pointed out that hand hygiene was not practiced immediately after removing soiled gloves. Residents Affected - Many

On 4/08/25 at 8:29 AM, Surveyor interviewed Licensed Practical Nurse (LPN) E who reported her expectations would be that if gloves are visibly soiled they be removed, and that hand hygiene should be performed immediately when gloves are removed.

On 4/10/25 at 8:45 AM, Surveyor interviewed RN C, who reported the expectation would be soiled gloves be removed, not wiped clean, and hand hygiene be performed immediately after removing gloves, and after resident incontinence cares. RN C acknowledged further infection control/hand hygiene education is required and will be provided.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 41 525507 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525507 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Golden Age Manor 220 Scholl CT Amery, WI 54001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or 48793 potential for actual harm Based on interview and record review, the facility did not establish an Infection Prevention and Control Residents Affected - Many Program (IPCP) that must include, at a minimum, the following elements: An Antibiotic Stewardship Program that includes antibiotic use protocols and a system to monitor antibiotic use. This has the potential to affect all 60 residents in the building who may utilize antibiotics.

The facility did not ensure a standard of practice for antibiotic use or surveillance was being utilized in the facility's antibiotic stewardship program.

This is evidenced by:

The Facility policy titled Antibiotic Stewardship Program, dated 10/23, states in part: The Infection Preventionist is responsible for monitoring; investigating and setting forth a control plan to prevent unnecessary infections. The IP is responsible for monitoring and trending the facility infection incidence rates and this information is reviewed quarterly assurance committee with the interdisciplinary team and medical director each at least quarterly .

Surveyor reviewed infection surveillance logs dated from February 2024-March 2025. Surveyor found missing documentation on all line lists for infection surveillance to include complete:

-Symptoms onset date.

-Culture/test type and result.

-Treatment parameters. Such as Antibiotics of choice and when started and stopped.

-Resolution date and times for infections.

On 04/10/25 at 11:12 AM, Surveyor interviewed Infection Preventionist, Registered Nurse (RN) C, about antibiotic tracking and surveillance. RN C indicated that RN C receives a printout from Health Direct on who was on antibiotics for the month. Surveyor asked RN C when RN C receives this report. RN C indicated the report is sent roughly two weeks after residents are started on antibiotics for that month and that is when RN C is reviewing antibiotic use.

Surveyor asked RN C how RN C is tracking infections, what kind of antibiotics residents are put on, and how RN C knows when residents are started on antibiotics and is it the correct antibiotic. RN C asked what Surveyor meant. RN C indicated that RN C leaves that up to the doctor to decide on antibiotic use. RN C stated, I am not a doctor. I don't know. Surveyor asked RN C what criteria is used to determine if an antibiotic is needed or that residents are on the correct antibiotic for their infections. RN C indicated to Surveyor that RN C is unsure what Surveyor is talking about. RN C indicated she does not have a process in place for monitoring correct antibiotic use for residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 41 525507 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525507 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Golden Age Manor 220 Scholl CT Amery, WI 54001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Surveyor asked RN C what criteria RN C utilizes such as the McGeer's or Loeb's criteria. RN C indicated RN C was not using either the McGeer's or Loeb's criteria at all. Surveyor referred RN C to the CDC guidelines Level of Harm - Minimal harm or for monitoring antibiotic use and utilizing McGeer's or Loeb's. RN C indicated that she would start utilizing the potential for actual harm McGeer's or Loeb's criteria.

Residents Affected - Many

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 41 525507 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525507 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Golden Age Manor 220 Scholl CT Amery, WI 54001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0887 Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51804

Residents Affected - Few Based on interview and record review, the facility did not maintain documentation of screening, education, and ensure offering of current Coronavirus 19 (COVID) vaccination for 1 of 5 residents (R) reviewed. (Resident R1)

This is evidenced by:

The facility policy titled Influenza and Pneumococcal Vaccinations, dated March 2022, does not refer to COVID vaccinations. This was the only policy provided when requested. Two requests for a related policy were made.

The CDC COVID 19 Staying Up to Date with Covid 19 Vaccines states in part: Everyone ages 6 months and older should get a 2024-2025 COVID 19 vaccine. It is especially important to get your 2024-2025 COVID 19 vaccine if you are ages 65 and older, are at high risk for severe Covid-19, or have never received a COVID 19 vaccine.

Resident R1 was admitted to the facility on [DATE REDACTED] and was admitted with the diagnoses that include: Alzheimer's disease, edema, urinary tract infection, polyneuropathy, chronic kidney disease stage 3b, dementia, depression, anxiety disorder, tremor, bipolar disorder, and insomnia.

Surveyor reviewed Resident R1's electronic medical record and noted it did not contain documentation of Resident R1 being screened and offered COVID 19 Immunization for 2024-2025 vaccination year. Surveyor requested documentation of immunization documentation in print. No documentation was available.

On 04/10/2025 at 8:05 AM, Surveyor interviewed Infection Preventionist (IP) C regarding immunizations. IP C stated that staff and residents are offered immunizations every year. If there is a Power of Attorney (POA) for the resident, then IP C sends them a letter with the education and consent form and follows up with the POA for questions and consent. IP C stated if the resident is their own person, then IP C educates and gets

the consent from them. IP C will get Surveyor copies of all Influenza, Pneumonia, and COVID consents and declinations for 2024/2025 vaccinations and the policy.

On 4/10/2025 at 8:56 AM, IP C provided Surveyor with written copies of consent and declination forms. IP C stated this is what IP C could find. There was no COVID consent or declination form for Resident R1. Surveyor asked IP C about COVID paperwork. IP C stated IP C did not think Resident R1 needed to be approached again because

she had declined in 2023.

On 4/10/2025 at 11:46 AM, IP C stated to Surveyor that she checked with pharmacy for consents and declinations and that was all we have.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 41 525507 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525507 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Golden Age Manor 220 Scholl CT Amery, WI 54001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51804

Residents Affected - Some Based on observation and interview, the facility did not ensure at least 100 square feet in a single resident room for 1 of 63 residents (R)58.

Resident R58 resides in a room that is less than the required 100 square feet in a single resident room.

This is evidenced by:

The state Operations Manual, titled Appendix PP- Guidance to Surveyors for Long Term Care Facilities, dated 8/8,24, states: Unless a variance has been applied for and approved under CFR (Code of Federal Regulation) 483.90 (e)(1)(ii), . (rooms must) Measure at least . 100 square feet in single resident rooms.

Resident R58 was admitted to the facility on [DATE REDACTED] with diagnoses atrial fibrillation, anxiety, depression, malnutrition, unspecified mental disorder due to unknown physiological concern and attention deficit hyperactivity disorder. Resident R58 scored as severely cognitively impaired, her speech is unclear but Resident R58 is rated to be able to make herself understood usually and understands others. Resident R58 is independently mobile and able to ambulate without assistance.

During the entrance conference, it was noted the facility has a room with less than the required square footage and is occupied by Resident R58. room [ROOM NUMBER] measures 96 1/2 square feet.

On 04/08/25 at 2:34 PM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding the size of room [ROOM NUMBER]. NHA A stated it's less than 100 square feet. NHA A stated we have not made any changes or done any remodeling. It is really only 4 sq. feet too small and not cost effective to remodel the room to expand. We have limited private rooms.

NHA A stated administration reviews the decision to continue to use the room annually. NHA A reported the patients that have been placed in that room like the room. NHA A stated that we explain to the residents and Power of Attorney (POA) the room size difference and they agree to the room before being placed in that room. NHA A stated we always put a smaller ambulatory person in the room. They have their own bathroom and privacy.

On 04/08/25 at 2:52 PM, Surveyor called Resident R58's POA and left a message on the phone to return the call to Surveyor. A return call was not received.

On 04/09/25, at 07:06 AM, Surveyor interviewed Resident R58. Resident R58 was up in her room watching TV. Resident R58 can't remember how long she has been in this room. Surveyor noted that she was admitted on [DATE REDACTED]. Resident R58 likes her small room, stating it is comfy. Resident R58 stated the size fits me well. My friends help me set it up. Resident R58 likes

the big window with a ledge to put her things on and stated she can see the sun.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 41 525507