Pavilion At Glacier Valley
Inspection Findings
F-Tag F0849
F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
morning of 9/6/25 for an end of life daily visit. Resident R1's family had Resident R1 up when HRN-C arrived. HRN-C indicated to staff in the room (who HRN-C thought was Licensed Practical Nurse (LPN)-D but was actually CNA-E who was also a Medication Technician) that if Resident R1 had a rally moment, it would be appropriate to get Resident R1 up but otherwise Resident R1 should remain in bed. Resident R1 was responsive during HRN-C's visit. HRN-C indicated LPN-D (who was actually CNA-E) was in the room for a period of time. Stopping medications and feeding and focusing on comfort was discussed. Resident R1 appeared comfortable at the beginning of the assessment but expressed pain when laid flat. An assessment indicated the pain was due to urinary issues. HRN-C had not ordered any scheduled medications for Resident R1 at that point. Resident R1 had orders for as needed (PRN) comfort pain medications.On 10/8/25, Surveyor attempted to contact LPN-D and CNA-E with no return phone calls.On 10/8/25 at 2:22 PM, Surveyor interviewed CNA-G who worked the 9/6/25 PM shift. CNA-G indicated CNAs do a 1:1 shift report; however, CNA-G could not find CNA-E for shift report that afternoon and was not told that Resident R1 was actively passing and should remain in bed. CNA-G did not get Resident R1 out of bed during CNA-G's shift. CNA-G indicated Resident R1's family visited most of the shift and it didn't look like Resident R1 should get out of bed.
CNA-G informed night shift CNA-H that Resident R1 didn't eat anything and had 50 cubic centimeters (ccs) of output
in Resident R1's catheter. On 10/8/25, Surveyor attempted to contact CNA-H with no return phone call. On 10/8/25 at 12:30 PM, Surveyor interviewed LPN-I who worked the night shift from 9/6/25 into 9/7/25. LPN-I indicated neither LPN-I or CNA-H were informed that Resident R1 was actively passing. LPN-I indicated Resident R1 slept all night and appeared comfortable. LPN-I and CNA-H got Resident R1 up in the morning per usual as Resident R1 was usually gotten up
on the night shift. LPN-I stated Resident R1 was Resident R1's usual self during the transfer. On 10/8/25, the facility provided Surveyor with a grievance filed by Resident R1's family that indicated Resident R1 was up in the morning on 9/7/25 and in pain when they arrived. The facility's investigation indicated HRN-C asked CNA-E not to get Resident R1 out of bed on the 9/6/25 AM shift but Resident R1 was gotten out of bed on the 9/6/25 PM shift. The investigation indicated verbal education was done with staff; however, the education was not signed or documented.On 10/8/25 at 1:35 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated DON-B spoke with HC-F to ensure
they informed their staff to communicate with the nurse on the shift instead of the CNA. DON-B indicated
the facility's investigation determined CNA-G was told that Resident R1 should not be gotten out of bed. Surveyor informed DON-B that if was actually AM shift CNA-E who was informed that Resident R1 should not be gotten out of bed and when CNA-G could not find CNA-E for shift report, the information was not relayed to CNA-G or communicated to night shift staff. DON-B confirmed staff should complete shift-to-shift reports. DON-B indicated verbal education was only completed with CNA-G (who worked the PM shift) despite the fact the Hospice note and interview with HRN-C indicated the Hospice visit occurred on the AM shift.
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Pavilion at Glacier Valley in Slinger, WI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Slinger, WI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Pavilion at Glacier Valley or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.