Pavilion At Glacier Valley
Pavilion at Glacier Valley in Slinger, WI — inspection on October 8, 2025.
Found 1 citation. 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
indicated LPN-D (who was actually CNA-E) was in the room for a period of time.
Stopping
due to urinary issues. HRN-C had not ordered any scheduled medications for R1 at that point. R1 had
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 R1 was actively passing and should remain in bed. CNA-G did not get R1 out of bed during CNA-G's shift. CNA-G indicated R1's family visited most of the shift and it didn't look like R1 should get out of bed. CNA-G informed night shift CNA-H that R1 didn't eat anything and had 50 cubic centimeters (ccs) of output in 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 R1 was actively passing. LPN-I indicated R1 slept all night and appeared comfortable. LPN-I and CNA-H got R1 up in the morning per usual as R1 was usually gotten up on the night shift. LPN-I stated R1 was R1's usual self during the transfer. On 10/8/25, the facility provided Surveyor with a grievance filed by R1's family that indicated 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 R1 out of bed on the 9/6/25 AM shift but 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 R1 should not be gotten out of bed.
Surveyor informed DON-B that if was actually AM shift CNA-E who was informed that 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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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.