Complete Care at Glendale West: Medication Left Unsecured - WI
The nurse responsible said it was fine. The resident, she explained, could self-administer his own medication.
He could not. There was no assessment saying he could. His own admission paperwork said the opposite.
The surveyor asked Licensed Practical Nurse I where to find the self-administration assessment that would authorize leaving medication unsupervised at a resident's bedside. The nurse said she didn't know where it would be. The surveyor then went to the Director of Nursing, who directed her to the quarterly and annual assessment section. What the surveyor found there was not an authorization. Both of the resident's Wisconsin Admit/Readmit assessments, listed under the self-administration section, answered the same question the same way: Does the resident desire to self-administer his or her own medications? No.
No other assessment existed. The surveyor looked and found nothing.
At 2:12 p.m., the surveyor returned to LPN-I with a direct question: how did she know this resident could self-administer his medication?
"He can't," the nurse said. "I was wrong, sorry."
That was the full explanation. No incident report. No account of how the tablets came to be sitting there, unsecured, tipped over on the table. Just an apology and a correction.
At 3:05 p.m., during the end-of-day meeting, the surveyor informed Nursing Home Administrator A, Director of Nursing B, and Regional Registered Nurse M about what she had found. The medication had been left without any assessment on file to justify it. Nobody in that room offered any additional explanation for why it had happened.
The violation was cited under F0554, with a harm level of minimal harm or potential for actual harm, affecting few residents.
The classification matters less than the sequence of events. A nurse left medication at a resident's bedside. She believed, or said she believed, that he was authorized to manage it himself. When asked to show the paperwork supporting that belief, she couldn't point to it. When the surveyor found the paperwork that existed, it said the opposite of what the nurse had assumed. When confronted with that, the nurse did not explain how the confusion arose. She said she was wrong and apologized.
What the inspection report does not contain is any account of how long this had been happening. The surveyor observed two tablets in a tipped bottle on a single afternoon. Whether medication had been left at this resident's bedside on prior days, and whether he had taken it unsupervised before anyone noticed, the report does not say.
The administrator and director of nursing, told about it at the end of the day, provided no information either.
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.
The nurse responsible said it was fine.
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.