Cycle 1
Health 2025-04-10 · Fire 2025-04-10
15 health deficiencies
Top issue: Infection Control (3 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Amery, WI
Golden Age Manor
1-star overall rating with 2-star inspections with 15 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
220 Scholl Ct, Amery, WI
(715) 268-7107
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
85
Certified beds
Average residents
63
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1993-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
2,779
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
47.79
Composite VBP score used to determine payment impact.
Payment multiplier
1.0014
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.51
Performance 18.41% · Measure score 6.51 · Achievement 6.51 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
2.96
Baseline 7.63% · Performance 6.95% · Measure score 2.96 · Achievement 2.96 · Improvement 2.09
Total nurse turnover
5.26
Performance 42.19% · Measure score 5.26 · Achievement 5.26 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
4.38
Baseline 3.84 hours · Performance 4.32 hours · Measure score 4.38 · Achievement 4.38 · Improvement 2.02
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.54% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 43 · Observed rate 16.28% · Lower 95% interval 7.86% |
| Discharge to community | 49.82% |
50.57%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 41.67% · Lower 95% interval 36% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 56 · Denominator 56 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 56 |
| Discharge self-care score | 23.91% |
53.69%
29.8 pts worse
|
Numerator 11 · Denominator 46 |
| Discharge mobility score | 32.61% |
50.94%
18.3 pts worse
|
Numerator 15 · Denominator 46 |
| Pressure ulcers or injuries, new or worsened | 5.36% |
2.29%
3.1 pts worse
|
Numerator 3 · Denominator 56 · Adjusted rate 6.66% |
| Healthcare-associated infections requiring hospitalization | 6.95% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 31 · Observed rate 6.45% · Lower 95% interval 3.74% |
| Staff COVID-19 vaccination coverage | 8.7% |
8.2%
0.5 pts better
|
Numerator 10 · Denominator 115 |
| Staff flu vaccination coverage | 28.43% |
42%
13.6 pts worse
|
Numerator 58 · Denominator 204 |
| Discharge function score | 54.35% |
56.45%
2.1 pts worse
|
Numerator 25 · Denominator 46 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 95.65% |
96.28%
0.6 pts worse
|
Numerator 22 · Denominator 23 |
| Resident COVID-19 vaccinations up to date | 50% |
25.2%
24.8 pts better
|
Numerator 17 · Denominator 34 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.6
0.2 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.2 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.7 |
2.2
0.5 pts worse
|
1.8
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.5 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
95.7%
3.8 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.2% · 4Q avg 99.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.7% |
3.2%
0.5 pts worse
|
3.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 3.6% · Q3 3.6% · Q4 5.3% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.2% |
5.0%
4.2 pts worse
|
11.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 5.9% · Q3 15.2% · Q4 7.8% · 4Q avg 9.2% |
| Percentage of long-stay residents who lose too much weight | 5.2% |
4.9%
0.3 pts worse
|
5.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 4.3% · Q3 2.0% · Q4 9.6% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.1% |
16.6%
10.5 pts worse
|
19.6%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 26.4% · Q3 30.0% · Q4 30.8% · 4Q avg 27.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 29.4% |
16.7%
12.7 pts worse
|
16.7%
12.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.2% · Q2 36.1% · Q3 29.7% · Q4 26.3% · 4Q avg 29.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.5% |
0.1%
0.4 pts worse
|
0.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.9% |
21.1%
3.2 pts better
|
16.3%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 24.3% · Q3 20.8% · Q4 8.4% · 4Q avg 17.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.1% |
17.3%
1.8 pts worse
|
14.9%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 21.6% · Q3 22.4% · Q4 12.2% · 4Q avg 19.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.7% |
2.3%
1.4 pts worse
|
1.0%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 0.0% · Q3 3.8% · Q4 5.1% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.8% |
3.0%
0.2 pts better
|
1.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 3.8% · Q3 1.9% · Q4 3.5% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.1% |
25.5%
3.4 pts better
|
19.8%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 24.7% · Q3 24.0% · Q4 19.3% · 4Q avg 22.1% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
5.5%
1.8 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 5.0% · Q3 2.5% · Q4 4.5% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.5% |
86.8%
2.7 pts better
|
81.7%
7.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 85.3% · Q3 85.7% · Q4 90.0% · 4Q avg 89.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.5% |
15.0%
4.5 pts worse
|
12.0%
7.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.5% · Observed 18.2% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.1% |
82.2%
11.9 pts better
|
79.7%
14.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 0.0% |
22.7%
22.7 pts better
|
23.9%
23.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 20.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-07 · Fire 2024-03-07
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-02-07 · Fire 2023-02-07
3 health deficiencies
Top issue: Environmental (1 deficiency)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-10
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-05-22
F · Potential for more than minimal harm
2025-04-10
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2025-05-22
F · Potential for more than minimal harm
2025-04-10
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-05-22
F · Potential for more than minimal harm
2025-04-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-22
F · Potential for more than minimal harm
2025-04-10
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-05-22
E · Potential for more than minimal harm
2025-04-10
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-05-22
E · Potential for more than minimal harm
2025-04-10
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-05-22
D · Potential for more than minimal harm
2025-04-10
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-05-22
D · Potential for more than minimal harm
2025-04-10
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2025-05-22
D · Potential for more than minimal harm
2025-04-10
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2025-05-22
D · Potential for more than minimal harm
2025-04-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-22
D · Potential for more than minimal harm
2025-04-10
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-05-22
D · Potential for more than minimal harm
2024-03-07
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-03-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-03-29
E · Potential for more than minimal harm
2023-02-07
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-03-01
E · Potential for more than minimal harm
2023-02-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-01
E · Potential for more than minimal harm
2023-02-07
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-03-01
C · Minimal harm
2023-02-07
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-03-01
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-10
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2025-05-22
F · Potential for more than minimal harm
2025-04-10
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-05-22
F · Potential for more than minimal harm
2025-04-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-22
F · Potential for more than minimal harm
2025-04-10
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-05-22
E · Potential for more than minimal harm
2025-04-10
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-05-22
E · Potential for more than minimal harm
2025-04-10
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-05-22
D · Potential for more than minimal harm
2025-04-10
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-05-22
D · Potential for more than minimal harm
2025-04-10
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-05-22
D · Potential for more than minimal harm
2025-04-10
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-05-22
D · Potential for more than minimal harm
2025-04-10
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-05-22
D · Potential for more than minimal harm
2025-04-10
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-05-22
D · Potential for more than minimal harm
2025-04-10
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-05-22
D · Potential for more than minimal harm
2025-04-10
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-05-22
D · Potential for more than minimal harm
2025-04-10
F887 · Infection Control Deficiencies
Health
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.
Corrected 2025-05-22
B · Minimal harm
2025-04-10
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2025-05-22
D · Potential for more than minimal harm
2024-09-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-22
G · Actual harm
2024-03-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-03
F · Potential for more than minimal harm
2024-03-07
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-03
E · Potential for more than minimal harm
2024-03-07
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-04-03
D · Potential for more than minimal harm
2024-03-07
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-04-03
D · Potential for more than minimal harm
2024-03-07
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-03
D · Potential for more than minimal harm
2024-03-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-03
B · Minimal harm
2024-03-07
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2024-04-03
D · Potential for more than minimal harm
2023-02-07
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-03-07
D · Potential for more than minimal harm
2023-02-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-07
B · Minimal harm
2023-02-07
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2023-03-07
Penalties and ownership
What sits behind the stars
Ownership
Polk County-Dept Of Administration
5% Or Greater Direct Ownership Interest · Organization
Polk County-Dept Of Administration
Operational/Managerial Control · Organization
Reese, Dana
Operational/Managerial Control · Individual
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2-star overall rating with 2-star inspections with $129,124 in total fines with 9 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
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4-star overall rating with 3-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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