Complete Care at Glendale West: Falsified Shower Records - WI
The CNA, identified in inspection records only as CNA-Q, told a federal surveyor on November 11 that she had never given the resident, identified as R2, a shower. Only bed baths. And during those bed baths, she said, she did not wash R2's hair.
When the surveyor asked why she had been signing the Body Audit Forms to indicate showers had been provided, CNA-Q said she had simply documented a shower on paper. She said she did not know of anyone on staff who had ever given R2 a shower.
The reason, she explained, was the chair.
The facility did not have a shower chair that fit R2 because of R2's weight, CNA-Q told the surveyor. R2's hips were too large for the available chair. Staff were afraid R2 would slide off and be injured. CNA-Q said she had repeated concerns that R2 would slide out or fall. Everyone, she said, felt it was too unsafe to use the equipment on hand.
So instead of reporting the problem or seeking a solution, staff documented showers that were not happening. The falsified entries stretched across months. Records show no shower documented on October 8, October 18, October 29, or October 31. In September, Body Audit Forms for at least two dates failed to record whether R2 had received a tub bath or shower at all. An August 27 bed bath entry was not signed by either the CNA or the nurse. A November 1 form was not signed by the CNA who supposedly provided the shower.
R2 was scheduled to receive showers on Wednesdays and Saturdays.
The unit manager, identified as UM-N, told the surveyor that if a resident refuses a shower, the nurse should be informed and the refusal documented in the electronic medical record. UM-N said she did not recall whether R2's feet had been a barrier to receiving showers. The social worker, SW-S, said she was not aware of R2 refusing showers at all.
Refusal was not the issue. Equipment was.
When the surveyor brought the findings to Nursing Home Administrator A, Director of Nursing B, and Regional Registered Nurse M that same afternoon, the response confirmed the problem extended beyond one resident. Staff informed the surveyor that the facility did not have appropriate equipment to give residents showers, including shower chairs of adequate size and shower cots.
The facility provided no further explanation for why R2 had not received scheduled showers on a consistent basis.
The inspection was conducted on November 12, 2025, and the deficiency was cited under the federal tag governing basic personal hygiene and grooming services. CMS rated the level of harm as minimal harm or potential for actual harm, affecting a few residents.
What the rating does not capture is the gap between what the records said and what was actually happening to R2, week after week. A resident whose body required equipment the facility did not own, whose scheduled showers were being replaced with unsigned forms and invented entries, whose hair went unwashed during the bed baths given in place of showers nobody would provide.
CNA-Q signed most of the Body Audit Forms. She knew. She said so.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Complete Care At Glendale West from 2025-11-12 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 22, 2026 · Our methodology
Complete Care at Glendale West in GLENDALE, WI was cited for violations during a health inspection on November 12, 2025.
And during those bed baths, she said, she did not wash R2's hair.
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.