Complete Care at Glendale West: Sepsis Missed - WI
Nobody at the facility had started an investigation by the time state inspectors arrived nearly three months later.
The nurse practitioner at the receiving physician's office, identified in inspection records as NP-V, told the surveyor he called the emergency room at 10:15 that morning after the resident, identified as R1, arrived at the appointment. NP-V said it was "a good thing R1 came in as sepsis doesn't go away."
The licensed practical nurse who prepared R1 for transport that morning, LPN-K, told the surveyor that R1 had complained of pain that morning. He took R1's vital signs. When the surveyor asked whether he had checked R1's urinary collection bag before the resident left the facility, LPN-K said he couldn't recall.
LPN-K also told the surveyor there was no place in the system to document the vital signs he had taken, because whoever entered the order had entered it incorrectly. The surveyor asked whether LPN-K had flagged that documentation problem to anyone. He had not. He said there were other residents on the unit with the same order, same problem.
LPN-K transferred R1 into a wheelchair himself using a slide board, brought him to the front of the facility, and sent him to his appointment.
The director of nursing, DON-B, met with the surveyor on the morning of November 12 alongside the nursing home administrator. DON-B offered several observations: R1's family had visited on August 24 and hadn't reported any concerns. R1 had done therapy on August 25 and was "fine." R1 had eaten 50 to 100 percent of his meals the day before, which showed a good appetite. The wound care nurse practitioner had seen R1 on August 21 and "don't just look at the wound."
The surveyor asked DON-B directly: after the facility received the call from the hospital emergency department, was there any investigation?
DON-B said no one came to her "until you guys showed up."
DON-B acknowledged that nursing aides have a tool available called a "stop and watch" to flag residents showing signs of change. The CNAs had not used it. She noted there were "dynamics between the CNA and nurse" without elaborating.
The response after the hospitalization, DON-B said, was a conversation with R1's family, education provided on urinary tract infections, and a plan for the management team to check residents before appointments going forward.
The inspection report notes that LPN-K told the surveyor R1 had asked for a pain pill on August 25. LPN-K said R1 "did not say anything" when asked whether he wasn't feeling well, but confirmed the pain complaint the following morning, the day of transport. LPN-K said he spoke with an advanced practice nurse prescriber, identified as APNP-P, who was at the facility and with whom he discussed R1 and other residents on the unit every other day.
The surveyor attempted to reach LPN-K twice on November 12, leaving a message at 8:14 a.m. before LPN-K called back at 9:28 a.m.
CMS rated the violation at a level of minimal harm or potential for actual harm. The resident had already been hospitalized with sepsis and acute kidney injury before inspectors ever asked a single question.
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.
Nobody at the facility had started an investigation by the time state inspectors arrived nearly three months later.
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.