Pavilion at Glacier Valley: Hospice Breakdown Harms Dying Resident - WI
The inspection report, completed October 8, 2025, documents what happened at Pavilion at Glacier Valley after that hospice visit fell apart in the handoff between shifts.
The hospice registered nurse, identified in the report as HRN-C, arrived for an end-of-life daily visit and found the resident, identified only as R1, already up with family. HRN-C spoke to the person in the room about keeping R1 in bed, believing that person was a licensed practical nurse. It was actually a certified nursing assistant who also worked as a medication technician, identified as CNA-E. R1 had expressed pain when laid flat, and an assessment traced it to urinary issues. No scheduled medications had been ordered yet. R1 had only as-needed comfort medications available.
That misidentification set off a chain of failures that ran through three shifts.
When the afternoon shift began, CNA-G could not find CNA-E for the standard one-to-one shift report. Nobody told CNA-G that R1 was actively dying and should stay in bed. CNA-G did not move R1 that shift, reading the situation from the family's presence and R1's condition, but also never received any formal communication about what the hospice nurse had said. CNA-G passed along to the night shift only that R1 had not eaten and had 50 cubic centimeters of output in her catheter.
The night shift nurse, LPN-I, and the night shift aide, CNA-H, also received no information that R1 was actively passing. R1 slept through the night and appeared comfortable. In the morning, as they usually did on the night shift, LPN-I and CNA-H got R1 up. LPN-I told the surveyor that R1 seemed like her usual self during the transfer.
When R1's family arrived that morning, September 7th, R1 was up and in pain. They filed a grievance with the facility.
The facility conducted its own investigation and concluded that CNA-E had been told not to get R1 out of bed on the morning shift, but that R1 had been moved on the afternoon shift. The facility said verbal education was completed with staff. That education was not signed or documented.
When the surveyor interviewed the Director of Nursing, identified as DON-B, the director said the facility had spoken with the hospice company to make sure their staff communicated with nurses rather than aides going forward. DON-B also said the investigation had determined CNA-G was the one who had been told to keep R1 in bed.
The surveyor corrected that. It was CNA-E, on the morning shift, who received the instruction. When CNA-G couldn't locate CNA-E for shift report, the information was simply lost. DON-B confirmed that staff are supposed to complete shift-to-shift reports.
The facility's own corrective education had targeted the wrong person. DON-B acknowledged that verbal education had been completed only with CNA-G, the afternoon aide, despite the hospice note and HRN-C's own account both pointing to the morning shift as when the instruction was given.
The surveyor attempted to reach CNA-E, CNA-H, and LPN-D by phone on October 8th. None returned the calls.
The inspection cited the facility under F0849, governing the quality of care provided to residents, at a level of minimal harm or potential for actual harm, affecting a small number of residents.
R1's family had been there through most of the afternoon shift on September 6th, watching. They filed the grievance. They were the ones who found her in pain the next morning.
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.
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: August 4, 2026 · Our methodology
Pavilion at Glacier Valley in Slinger, WI was cited for violations during a health inspection on October 8, 2025.
HRN-C spoke to the person in the room about keeping R1 in bed, believing that person was a licensed practical nurse.
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.