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
morning of 9/6/25 for an end of life daily visit. R1's family had 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 R1 had a rally moment, it would be appropriate to get R1 up but otherwise R1 should remain in bed. 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. 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 R1 at that point. 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 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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