Complete Care At Glendale West
Complete Care at Glendale West in GLENDALE, WI — inspection on November 12, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
tipped on the side and still contains two Tylenol tablets.On 11/11/25, at 1:44 p.m., Surveyor asked Licensed Practical Nurse (LPN)-I if she usually leaves R1's medication. LPN-I replied he can self-administer his medication.
Surveyor asked LPN-I if she knew where Surveyor would be able to locate R1's self-administration medication assessment. LPN-I informed Surveyor she did not.On 11/11/25, at 1:47 p.m., Surveyor asked Director of Nursing (DON)-B where Surveyor would be able to locate self-administration medication assessments.
Regional Registered Nurse (R)-M, who was in DON-B's office, informed Surveyor it's under the assessment section quarterly/annual assessment.R1's WI (Wisconsin) Admit/Readmit assessment dated [DATE] under the self-administration section for the question Does the resident desire to self-administer his/her own medications, no is answered.R1's WI (Wisconsin) Admit/Readmit assessment dated [DATE] under the self-administration section for the question Does the resident desire to self-administer his/her own medications, no is answered.Surveyor was unable to locate a self-administration for medication assessment for R1.On 11/11/25, at 2:12 p.m., Surveyor asked LPN-I how she knew R1 could self-administer his medication. LPN-I replied he can't I was wrong, sorry.On 11/11/25, at 3:05 p.m., during the end of the day meeting Surveyor informed Nursing Home Administrator (NHA)-A, DON-B, and Regional RN-M, of the observation of R1's Tylenol being left on the overbed table without a self-administration medication assessment.No additional information was proved to Surveyor as to why R1's medication was left on the overbed table.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/12/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Complete Care at Glendale West
6263 N Green Bay Ave Glendale, WI 53209
SUMMARY STATEMENT OF DEFICIENCIES
8/27/25-R2 provided a bed bath and is not signed by the CNA and nurse
8/30/25- Body Audit Form does not document if R2 has had a tub bath or shower September
9/3/25- Body Audit Form does not document if R2 has had a tub bath or shower October 10/8/25, 10/18/25, 10/29/25, 10/31/25- no shower documented as being provided November 11/1/25- Body Audit Form is not signed by the CNA who provided the shower On 11/11/25, at 10:46 AM, Surveyor interviewed Unit Manager (UM)-N explained that if a resident refuses showers, the nurse should be informed and it should be documented in the resident's EMR. UM-N does not recall if R2's feet was a barrier to receiving showers.
On 11/11/25, at 12:13 PM, Surveyor interviewed CNA-Q.
Surveyor had noted that CNA-Q had signed a majority of R2's Body Audit Forms. CNA-Q states that CNA-Q has never given R2 a shower, only a bed bath. CNA-Q stated R2's hair is not washed with the bed bath. CNA-Q states that the facility does not have a shower chair that fits R2 due to R2's weight. CNA-Q specifically stated that R2's hips are too big for the shower chair. CNA-Q states that none of the staff give R2 a shower because everyone is afraid R2 will slide off the small shower chair and get injured. CNA-Q states its too unsafe to use the current available chair for R2. CNA-Q repeated that R2 will slide out or fall off.
Surveyor asked CNA-Q why CNA-Q signed the Body Audit Forms documenting R2 has received showers. CNA-Q explained that CNA-Q has never given R2 a shower, just documented on paper as a shower. CNA-Q stated CNA-Q does not know of anyone who gives R2 a shower.
On 11/11/25, at 12:34 PM, Social Worker (SW)-S informed Surveyor that SW-S is not aware of R2 refusing showers.
On 11/11/25, at 3:04 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A, DON-B and Regional Registered Nurse (RN)-M of R2 not receiving scheduled showers on Wednesday and Saturday on a consistent basis.
Surveyor shared staff have never given R2 a shower because the shower chair does not fit R2 and it would not be safe to provide a shower to R2.
Surveyor was informed by staff that the facility does not have appropriate equipment to give residents showers including appropriate sized shower chairs and shower cots.
No further information has been provided by the facility at this time as to why R2 did not receive scheduled showers on a consistent basis.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/12/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Complete Care at Glendale West
6263 N Green Bay Ave Glendale, WI 53209
SUMMARY STATEMENT OF DEFICIENCIES
urine or B. there something internally.
Physician Office NP-V stated no matter what R1 was an ER visit.
Physician Office NP-V informed Surveyor he made a phone call to the ER at 10:15 a.m. and R1 was admitted to the hospital with sepsis & acute kidney injury.
Physician Office NP-V informed Surveyor it's a good thing R1 came in as sepsis doesn't go away.On 11/12/25, at 8:14 a.m., Surveyor telephone LPN-K for the second time and left message asking for a return call.On 11/12/25, at 8:57 a.m., Nursing Home Administrator (NHA)-A and DON-B met with Surveyor. DON-B informed Surveyor R1's family member saw R1 on 8/24 and didn't complain and there was no information given to the nurse. R1 was seen by therapy on 8/25/25 and he did therapy and was fine. DON-B informed Surveyor LPN-K assessed R1 for opioid side effects. R1 was picked up at 9:19 a.m. and prior to being picked up he had a conversation with the receptionist, which the receptionist is writing a statement. DON-B informed Surveyor R1 was seen by the wound NP with the wound nurse on 8/21/25 and they don't just look at the wound. DON-B was asking if there was any documented full assessment.
Surveyor did not receive any assessment. DON-B informed Surveyor the day prior R1 ate 50% to 100% of meals which showed good appetite. DON-B informed Surveyor if something is going on with a resident the care givers can complete a stop and watch which the CNA's did not. DON-B indicated there are dynamics between the CNA & nurse. DON-B was asked after they received the call from the hospital ED was there any investigation. DON-B stated no one came to her until you guys showed up (referring to the survey team). DON-B indicated she spoke with R1's family there was nothing negative, did education on UTI and management team is going to check residents prior to their appointment for any issues. On 11/12/25, at 9:28 a.m., LPN-K telephoned Surveyor.
Surveyor asked LPN-K about R1 on 8/25/25 & 8/26/25 and inquired if R1 told him he wasn't feeling good. LPN-K informed Surveyor R1 did not say anything. R1 asked if he could have a pain pill, and he took his vital signs. LPN-K informed Surveyor they don't have anywhere to record the vital signs as whoever did the order did the order incorrectly.
Surveyor asked LPN-K if he mentioned there is no place to document the vital signs. LPN-K replied no explaining there are a number of residents with the same order.
Surveyor asked LPN-K who helped transfer R1 into the wheelchair on 8/26/25. LPN-K informed Surveyor he did it himself with a slide board.
Surveyor asked LPN-K before R1 left for the doctor's appointment did he check R1's urinary collection bag. LPN-K informed Surveyor he couldn't recall.
Surveyor asked LPN-K if R1 complained of pain on 8/26/25. LPN-K informed Surveyor he complained of pain that morning.
Surveyor asked LPN-K if he spoke to anyone. LPN-K informed Surveyor APNP (advance practice nurse prescriber)-P is at the facility, and he speaks to APNP-P about R1 and every resident on the unit every other day.
Surveyor asked LPN-K who brought R1 to the front for transportation. LPN-K informed Surveyor he did.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/12/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Complete Care at Glendale West
6263 N Green Bay Ave Glendale, WI 53209
SUMMARY STATEMENT OF DEFICIENCIES
urinary collection bag lying directly on the floor.On 11/11/25, at 3:00 p.m.
Surveyor asked ADON-D what the expectation regarding hand hygiene is. ADON-D explained with all her training and years of work the expectation is if change gloves wash hands in between.
Change gloves when visibly soiled or if providing peri care.
Surveyor asked during cares after cleaning a resident who had a bowel movement should they remove their gloves & perform hand hygiene before doing the next task. ADON-D replied yes and explained dealing with an area with fecal matter.
Surveyor informed ADON-D of hand hygiene concerns observed.On 11/11/25, at 3:05 p.m., during the end of the day meeting Nursing Home Administrator (NHA)-A, DON-B, and Regional RN-M were informed of the above.
Facility ID: