Pavilion at Glacier Valley: Hospice Communication Failure - WI
The inspection at Pavilion at Glacier Valley, completed October 8, 2025, traced what happened after a hospice nurse visited on the morning of September 6. The nurse told the aide on the AM shift, CNA-E, that the resident, identified only as R1, should stay in bed. Stopping medications and feeding and focusing on comfort had been discussed. R1 had orders for as-needed pain medications but no scheduled comfort medications had been ordered yet.
When the PM shift began that afternoon, CNA-G could not find CNA-E for the standard shift-to-shift handoff report. Nobody told CNA-G that R1 was actively dying and should remain in bed. CNA-G did not get R1 out of bed that shift, though the reason was that family was visiting and R1 didn't look like she should be moved, not because anyone had communicated the hospice nurse's instructions. CNA-G passed along to the night shift only that R1 hadn't eaten and had minimal catheter output.
The night shift nurse, LPN-I, and the night aide were also never told R1 was actively passing. LPN-I said R1 slept through the night and seemed comfortable. In the morning, per their usual routine, they got R1 up. LPN-I described R1 as her usual self during the transfer.
R1's family filed a grievance. They arrived that morning to find her up and in pain.
The facility's own investigation confirmed CNA-E had been told to keep R1 in bed but that R1 was gotten up on the PM shift. The Director of Nursing told the surveyor the facility had determined CNA-G was the one who needed education. The surveyor corrected her: it was CNA-E on the AM shift who received the hospice nurse's instructions, and when CNA-G couldn't find CNA-E for report, the information was lost entirely. The DON confirmed staff are supposed to complete shift-to-shift reports. The verbal education the facility documented was given only to CNA-G. It was never signed or documented for anyone else.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pavilion At Glacier Valley from 2025-10-08 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Pavilion at Glacier Valley in Slinger, WI was cited for violations during a health inspection on October 8, 2025.
The inspection at Pavilion at Glacier Valley, completed October 8, 2025, traced what happened after a hospice nurse visited on the morning of September 6.
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.