Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pavilion At Glacier Valley during CMS and state inspections, most recent first.
A resident with severely impaired cognition and an activated POAHC was involved in two family abuse incidents, including physical abuse and inappropriate sexual contact. Although police and APS were notified and a no contact order was issued for one family member, the resident’s care plan and medical record were not updated, and unit staff did not have visible information about the visitation restriction or supervision needs. Staff on the unit were unaware of the restrictions, while the front desk had a posting about the banned family member.
Direct care staffing postings were not posted at the beginning of the shift and did not include actual hours worked for RN, LPN, and CNA staff. Surveyors found a posting still dated the prior day, observed that the actual hours worked column was blank, and noted that the posted shift times did not match the nursing schedule or the CNA shift times identified by the NHA.
Menu substitutions, therapeutic diet items, and portion sizes were not followed during lunch service. A posted menu listed seasoned broccoli, a fresh baked roll, and cheesecake, but wax beans were served instead, residents on pureed diets received applesauce instead of cheesecake and no roll, and residents on consistent carbohydrate diets were served dinner rolls despite the menu restriction. The meal was also portioned incorrectly, with red beans, rice, and sausage served in smaller amounts than listed on the menu.
Unsafe food storage, preparation, and sanitizing practices were observed during kitchen operations. Staff did not consistently complete meal temperature logs, and an LPN-equivalent dietary staff member was observed handling ready-to-eat dinner rolls with the same gloved hand after touching clothing and other items. Clean bowls were stored upright instead of inverted, serving utensils were left uncovered near a fryer and toaster oven, the dishwasher rinse temperature did not meet the posted standard, and staff could not locate or explain required dishwasher temperature testing or sanitizing bucket PPM documentation.
The facility failed to notify a resident’s primary POA of new skin abrasions identified during a care conference. The resident, who had an activated healthcare POA and intact cognition, developed a chronic open area on the left ear and an abrasion on the left side of the head related to phone use and BiPAP straps. Staff measured and documented the wounds and discussed them in person with the alternate POA, who attended the care conference at the request of the primary POA during a brief period of unavailability. However, the primary POA was not directly informed by facility staff of these new skin conditions and instead learned of them from the alternate POA, despite documentation indicating the primary POA remained the main healthcare agent when available.
A resident with dementia and moderate cognitive impairment did not have a care plan with dementia goals or interventions. Staff, including an LPN, ADON, SW, and NHA, confirmed the resident should have had a dementia care plan, but the record review showed none was in place.
Two residents did not receive care consistent with orders and clinical information. One resident with DM had no BG notification parameters in the orders, no DM care plan, and had repeated high BG readings without documented MD notification after a hospitalization for hypoglycemia and a change from insulin to Januvia. Another resident with CHF, renal failure, edema, and DM returned from a hospitalization with discharge and cardiology instructions for a fluid restriction, but the facility did not implement a fluid restriction despite a consistent carbohydrate/no added salt diet order and daily weight monitoring.
Food preferences were not followed for two residents during lunch service. One resident with intact cognition had a documented dislike of sausage but was initially served a sausage-containing entree, and another resident with moderate cognitive impairment was initially served a meal without the documented half cup of super potatoes listed on the meal ticket. The CDM later acknowledged the missed preferences, and the NHA verified that residents should receive the preferences noted on their meal tickets.
A resident with C-diff, heart failure, and DM2 was placed on contact precautions for loose stools, but staff brought the resident to the dining room for breakfast and seated the resident with other residents. The resident had reported diarrhea and poor appetite, and the facility policy stated the resident should remain in the room during transmission-based precautions unless medically necessary care was needed. A CNA said the resident’s illness was not communicated in morning report and the contact precautions sign was missed; an ADON confirmed the resident should have eaten in the room.
A deficiency occurred when a resident receiving hospice care was not provided with coordinated end-of-life services due to a breakdown in communication between staff shifts. The hospice RN instructed a CNA that the resident should remain in bed, but this information was not passed on to PM or night shift staff, resulting in the resident being gotten out of bed as per routine. The resident, who had dementia and a lumbar fracture, exhibited signs of active decline, but the lack of shift-to-shift reporting led to care inconsistent with the hospice plan.
Staff did not follow enhanced barrier precautions (EBP) during high-contact care activities for two residents with wounds and indwelling devices. Despite posted EBP signs, staff either did not use required PPE or were unsure of the need for it, and PPE supplies such as gowns were not available near the rooms. The DON confirmed that PPE should have been used during these care activities.
The facility did not have a qualified individual designated as the food and nutrition services director. The Dietary Manager (DM-N) lacked the necessary certification and was not enrolled in an approved course, despite having a ServSafe certification. The Nursing Home Administrator (NHA-A) confirmed this deficiency and stated that the facility was reviewing course options for DM-N and other kitchen staff. This oversight had the potential to impact all 72 residents.
The facility failed to provide adequate staffing, resulting in unmet resident needs. Residents experienced delays in assistance, with staff turning off call lights without providing help. Staffing shortages were noted on specific dates, and scheduled showers were inconsistently provided. Staff interviews confirmed concerns about insufficient staffing, particularly on weekends and night shifts.
The facility failed to provide timely and consistent assistance with ADLs for six residents, leading to multiple deficiencies. Residents experienced delays in transfers, inadequate toileting assistance, and inconsistent showering schedules. Documentation was incomplete, and staff often turned off call lights without providing necessary care.
The facility failed to properly store and label medications, as observed by surveyors. An unlocked and unattended medication cart was found with exposed resident information, and expired medications were present in the storage room. Additionally, a medication label discrepancy was noted for a resident, with the RN confirming the label was incorrect.
A resident's medications were administered late on several occasions due to staffing issues and emergencies, despite the facility's policy requiring timely administration. The resident, who was cognitively intact and had multiple diagnoses, experienced delays in medication administration due to an agency nurse arriving late, a resident in respiratory distress, and other emergencies. These issues were documented in the resident's medical record and were the subject of a grievance filed by the resident's Power of Attorney.
A resident with a traumatic brain injury and legal blindness was found without access to a call light, which was placed out of reach. The resident, dependent on staff for mobility, confirmed the inability to reach the call light and phone. An agency CNA, new to the facility, failed to ensure the call light was accessible, contrary to the resident's care plan and facility policy.
A resident reported missing personal items, but the facility failed to follow its grievance process. Despite the resident's cognitive intactness, staff did not complete a grievance form or communicate the issue to the appropriate personnel, resulting in unresolved grievances.
Three residents in a LTC facility did not receive adequate pressure ulcer care and prevention. A resident with a heel ulcer was observed wearing shoes against wound care recommendations. Another resident developed a pressure injury from unpadded oxygen tubing, and a third resident's care plan failed to address skin injury risks from a urinal placement. Staff did not follow care plans or adequately monitor skin integrity.
Three residents in the facility did not receive consistent restorative therapy as required by their care plans. One resident did not have therapy recommendations correctly entered into their medical record, leading to an incorrect MDS assessment. Another resident's therapy documentation showed significant gaps, and a third resident reported that ROM exercises were not consistently performed. Interviews and record reviews confirmed these deficiencies.
A resident with chronic kidney disease and recurrent hematuria, receiving hospice services, had an indwelling Foley catheter with a physician order for a privacy bag. The catheter drainage bag was observed uncovered and placed on the floor, contrary to the facility's policy to prevent CAUTI. The infection preventionist, a registered nurse, and the Director of Nursing confirmed the deficiency in catheter care.
A facility failed to ensure proper management of oxygen therapy for a resident with COPD, CHF, and CKD stage 3. The resident's oxygen tubing was not labeled with the date or initials of the staff who changed it, as required by facility policy. The Director of Nursing confirmed the oversight, noting that the tubing should have been labeled during the scheduled weekly change.
A resident with specific dietary needs due to medical conditions did not consistently receive meals according to their preferences at a facility. Despite having a clear plan of care, the resident was served inappropriate foods, such as meatloaf instead of a deli sandwich and wheat bread instead of white bread. The Dietary Manager had not updated the meal ticket system with the resident's preferences, leading to repeated dissatisfaction and the resident's family bringing in food.
A resident with venous ulcers requiring enhanced barrier precautions (EBP) did not have the necessary signage posted outside their room to inform staff of infection prevention measures. The absence of EBP signage was confirmed by the LPN, IP, and DON, despite the facility's policy requiring such signage for residents with wounds.
The facility failed to ensure timely medication administration for three residents, with medications given beyond the allowed time window. Additionally, improper handling of medications was observed, including incorrect disposal of a dropped aspirin and a refused sertraline tablet. A medication cart was also left unlocked and unattended, posing a security risk.
A resident experienced an 8.11% weight loss over one week, but the facility failed to notify the physician as required by policy. The resident, with multiple health conditions and intact cognition, was responsible for their healthcare decisions. Despite the facility's policy mandating notification for significant weight changes, the physician was not informed due to the resident's discharge, as confirmed by the DON.
A resident's representative submitted multiple grievances regarding care issues, including unsanitary conditions and late medication administration. The facility failed to document these grievances, investigate them, or provide resolutions, as required by their grievance policy. Interviews with the DON and NHA confirmed the lack of documentation and follow-up communication.
A deficiency was identified when staff failed to report a resident-to-resident altercation involving two residents with vascular dementia. The CNA separated the residents but did not notify a nurse or the NHA, contrary to facility policy. Interviews revealed that none of the nursing staff were informed of the incident, leading to a delay in reporting to authorities.
A resident with cerebral infarction and hemiparesis did not receive appropriate care to maintain or improve range of motion (ROM) and mobility. The resident's care plan failed to include a hand splint and passive range of motion (PROM) exercises as ordered by the physician. Staff interviews revealed inconsistencies in the application of the hand splint and PROM exercises, and the Director of Nursing confirmed the care plan omissions.
Failure to Supervise and Document Family Abuse Restrictions
Penalty
Summary
The facility did not ensure adequate supervision and staff education for a resident following two incidents of familial abuse. The resident had diagnoses including cognitive communication deficit, CVA, insomnia, and depression, and had a BIMS score of 5 out of 10, indicating severely impaired cognition. The resident required moderate to substantial assistance with ADLs and had an activated POAHC. The facility’s abuse prevention policy stated residents have the right to be free from abuse, that all staff are mandatory reporters, and that the facility would implement immediate interventions to protect residents and document exact observations, notifications, interventions, witnesses, and relevant details. A facility-reported incident showed an ADON heard raised voices from the resident’s room, observed a family member yell at the resident, slap the resident on the hand, and forcefully grab the resident’s arms. Police were notified, and supervised visitation was implemented for that family member pending the investigation. The investigation later identified bruising on the resident’s arms and thumb. A second incident occurred when a speech therapist entered the room and observed another family member lying on the resident’s bed with a hand in the resident’s groin area. The therapist removed the resident from the room, and police and APS were notified. APS reported that a no contact order was initiated, and the family member was prohibited from contacting or visiting the resident and from entering the facility. The resident’s care plan did not accurately reflect the abuse incidents, the no contact order, or the restrictions on family visitation. Although the resident had a trauma-related care plan, it did not identify the family abuse, supervised visits, or the prohibition against the family member entering the facility. The resident’s medical record also did not contain documentation of the incidents. Surveyors found no posting or visible information at the nursing station on the resident’s unit to alert staff that the family member was not allowed in the building, and multiple staff members were unaware of the restriction or the need for supervised visitation. The receptionist showed a posting at the front desk, but staff on the unit did not have the same information available to them.
Direct care staffing postings were not timely or accurate
Penalty
Summary
The facility did not post required direct care staffing information in a timely or accurate manner. On 6/11/26 at 8:42 AM, the direct care staff posting at the reception desk was still dated 6/10/26, and the receptionist did not know when the 6/11/26 staffing information would be posted. The facility policy stated that the DON or designee shall post direct care staffing on a daily basis at the beginning of each shift and that the posting must include the total number and actual hours worked by RN, LPN/LVN, and CNA staff per shift. The 6/10/26 posting listed staff titles and handwritten counts for each shift, but the actual hours worked column was not completed, and the shift times shown were AM 6:00 AM-2:30 PM, PM 2:00 PM-10:30 PM, and NOC 10:00 PM-6:30 AM. On 6/11/26 at 9:11 AM, the 6/11/26 posting was observed, but the actual hours worked column still was not completed and the shift times remained the same as the prior day. At 9:30 AM, the posting was compared with the nursing schedule and the numbers matched, but one AM CNA was scheduled until 10:00 AM rather than the full shift, so the posting did not reflect actual hours worked, including whole and partial shifts. The staff coordinator stated the hours worked were based on census and that actual hours were not completed until the day was over, so they were not reflected on the daily posting for residents or visitors to see. Later review of postings from the last 12 months showed actual hours were entered after the posting was taken down. The NHA later identified CNA shift times that differed from the times listed on the posting, including PM and NOC CNA shifts that did not match the posted times.
Menu Substitutions and Portion Sizes Not Followed
Penalty
Summary
Menus and serving sizes were not followed for lunch service, and residents were not notified when a menu item was changed. On 2/17/26, the posted lunch menu in the dining room listed red beans, rice, and sausage, a fresh baked roll, seasoned broccoli, and cheesecake. Surveyor observation showed wax beans were served instead of broccoli, and the dietary staff member serving the meal was not sure why the vegetable had changed and did not think residents were notified. The Registered Dietitian confirmed residents should be notified if there are substitutions or changes to the menu. The facility also did not serve therapeutic and mechanically altered diets as planned. Residents with pureed diets, including two residents whose orders included pureed diets and large protein portions, did not receive a dinner roll and were given applesauce instead of cheesecake; dietary staff stated dinner rolls were not pureed and that cheesecake was not pureed because of uncertainty about the crust. The Registered Dietitian stated the top of the cheesecake could have been pureed for residents on pureed diets who should receive the same items as residents on regular diets. In addition, residents on consistent carbohydrate diets were served dinner rolls even though the extended menu indicated they should not receive them. Portion sizes were also not followed: the menu listed 8 ounces of red beans, rice, and sausage, but the observed scoops provided 6 ounces for regular diets and 4 ounces for pureed and mechanical diets.
Unsafe Food Storage, Preparation, and Sanitizing Practices
Penalty
Summary
Food was not consistently stored, prepared, distributed, and served in a sanitary manner during kitchen and dining observations, staff interviews, and record review. On an initial kitchen tour, the CK-G was not sure which food code the facility followed, and the NHA later stated the facility follows the FDA Food Code. Surveyor review of cooking and holding temperature logs showed missing documentation for dinner on 2/1/26, missing breakfast, lunch, and dinner temperatures on 2/12/26, 2/13/26, and 2/14/26, and a breakfast log on 2/15/26 that did not contain breakfast temperatures. CK-G stated the log had not been completed. During lunch meal service, CK-K was observed wearing gloves while taking serving temperatures, then touching scoop handles, making a grilled cheese sandwich, touching clothing, and continuing to place dinner rolls on plates with the same gloved hand. RD-J confirmed dinner rolls should be placed on plates with tongs or another utensil. The facility's Nutrition Policies and Procedures hand hygiene policy stated hands should be washed after contact with soiled or contaminated articles such as dirty dishes, and the FDA Food Code prohibits bare-hand contact with exposed ready-to-eat food. Additional kitchen observations showed clean mixing bowls stored upright instead of inverted, and uncovered plastic containers of serving utensils stored on a bottom shelf next to the deep fryer and beneath a toaster oven. Staff confirmed the bowls should be stored upside down and that the utensil bins should be covered, but stated the bins were too full to close. In the dishwashing area, staff used a mechanical hot water sanitizing dishwasher, but the rinse temperature observed was 172 degrees F while the posted log indicated 180 degrees F should be reached. Staff could not locate internal temperature test strips, did not know how often the dishwasher surface temperature should be tested, and the last internal test strip entry on the log was dated 2/6/26. Staff also did not have a log to document the PPM of the sanitizing solution in sanitizing buckets, and CK-K was unsure of the correct PPM when asked to test it.
Failure to Notify Primary POA of Resident’s New Skin Abrasions
Penalty
Summary
The deficiency involves the facility’s failure to notify the primary Power of Attorney for Healthcare (POAHC-M) of a change in condition for a resident with an activated healthcare power of attorney. The resident had multiple diagnoses, including traumatic brain injury, mild neurocognitive disorder with behavioral disturbance, delusional disorder, and muscle contractures, but had intact cognition with a BIMS score of 15/15. The POAHC document designated POAHC-M as the primary agent and POAHC-N as the alternate, to act only when POAHC-M was unavailable or unable, with POAHC-M resuming the role when again available. The resident’s facesheet instructed staff to call POAHC-M and, if there was no answer, to then call POAHC-N. On the date the new skin issues were identified, POAHC-M had emailed the facility stating they could not attend the care conference and had forwarded the invitation to POAHC-N, but there is no documentation that POAHC-M relinquished primary decision-making authority beyond this limited unavailability. On the day of the care conference, staff identified two new skin alterations: a chronic open area on the left ear related to phone use and poor neck strength, and an abrasion on the left side of the head from BiPAP straps. These areas were measured, documented, and discussed in person with POAHC-N, who attended the care conference and visited the resident weekly, but the facility did not notify POAHC-M of these new skin conditions. The wound care LPN confirmed discussing the left ear scab and head abrasion with POAHC-N at the conference. The Nursing Home Administrator stated that staff typically correspond with POAHC-M via email and that social services is designated to respond, and also acknowledged that POAHC-N, as the alternate POAHC, frequently interacts with staff and was present when the abrasions were discovered. POAHC-M later reported not being informed by the facility of the sores and learned of them from POAHC-N, who stated that POAHC-M had asked them to attend the care conference due to a brief period of unavailability and that they subsequently relayed information about the resident’s skin integrity to POAHC-M.
Missing Dementia Care Plan
Penalty
Summary
A comprehensive resident-centered care plan was not implemented for one sampled resident with dementia. R11 was admitted to the facility with a diagnosis of dementia, and the MDS dated 12/29/25 showed a BIMS score of 10 out of 15, indicating moderate cognitive impairment. The MDS also identified dementia, and R11 had an activated POAHC. However, review of R11's care plan showed that it did not contain dementia goals or interventions. During the survey, LPN-D confirmed that R11 had a diagnosis of dementia but did not have a dementia care plan. ADON-C also confirmed the absence of a dementia care plan and stated that Social Services was responsible for behavior care plans while nurses were responsible for other care plan areas. SW-E stated that Social Services was responsible for behavior-related care plan development and indicated that R11 should have a dementia care plan. The NHA-A further stated that R11 should have a care plan for dementia because it is a substantial diagnosis and has the potential to advance.
Failure to Follow Diabetes Monitoring and Fluid Restriction Orders
Penalty
Summary
Care and treatment were not provided in accordance with professional standards for two residents with diabetes and CHF. R39 was admitted with diagnoses including type 2 diabetes, CHF, and a left below-the-knee amputation, and had intact cognition. After a hospitalization for hypoglycemia, R39 returned to the facility on insulin orders that did not include parameters for physician notification related to high or low blood sugars. R39’s care plan did not identify diabetes, and the generic medication care plan did not specify which medications R39 was taking. R39 continued to have elevated blood sugars after the hospitalization, including readings of 458 and 386, with no documented physician notification for those values. The facility’s ADON confirmed that R39 should have had a diabetic care plan and that, when no blood sugar parameters are in place, the facility follows physician notification for blood sugar under 70 or over 350. The ADON also verified that the physician was not notified of the high blood sugars on those dates. The NP indicated parameters are not generally done for residents who are not on insulin, but R39 had previously been on Humulin insulin before the hospitalization and was later changed to Januvia. R55 was admitted with diagnoses including acute on chronic renal failure, severe bilateral lower extremity edema, type 2 diabetes, and CHF, and had intact cognition. After hospitalization for significant weight gain, worsening edema, and failed outpatient diuretic escalation, hospital discharge paperwork and a nutrition assessment indicated a consistent carbohydrate diet with a 2 liter fluid restriction, and a cardiology follow-up also stated to drink less than 2 liters per day. Although the facility had a consistent carbohydrate/no added salt diet order and monitored daily weights, it did not implement a fluid restriction for R55, and the medical record did not indicate that one was in place.
Food Preferences Not Followed During Meal Service
Penalty
Summary
Food preferences were not followed for 2 of 14 sampled residents, R16 and R58. R16’s meal ticket indicated a dislike of sausage, and R16 had a BIMS score of 15 out of 15 on the 1/21/26 MDS, showing intact cognition. R16 was also identified as at risk for malnutrition. During lunch service on 2/17/26, the surveyor observed the certified dietary manager (CK-K) place the main entree of red beans, rice, and sausage on R16’s plate despite the documented dislike of sausage. CK-K later stated the preference was missed on the meal ticket and made R16 a grilled cheese sandwich. R58’s meal ticket indicated R58 should receive a half cup of super potatoes for lunch. R58’s 2/17/26 MDS showed a BIMS score of 11 out of 15, indicating moderate cognitive impairment, and also identified R58 as at risk for malnutrition. During the same lunch service, the surveyor observed CK-K place red beans, rice, sausage, a dinner roll, and wax beans on R58’s plate without the super potatoes, then hand the plate to the dietary aide to serve. When asked about the missing item, CK-K stated the super potatoes had been missed on the meal ticket, and R58 was then given a half cup of super potatoes. The NHA later verified that food preferences were not followed and stated residents should receive preferences noted on meal tickets and staff should check tickets and plates for accuracy before meals are served.
Resident on Contact Precautions Was Taken to Dining Room
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for one resident, R39, who was on contact precautions due to loose stools. The facility policy stated that contact precautions should be used when a resident has diarrhea that cannot be contained and that the resident should remain in the room for the duration of transmission-based precautions unless medically necessary care was needed. R39 was admitted with diagnoses including C-difficile, heart failure, and type 2 diabetes, and had a BIMS score of 15 out of 15, indicating intact cognition. R39 reported having diarrhea all morning and was not feeling well, and a progress note later documented multiple loose bowel movements, watery stools, and a poor appetite. Contact isolation was started later that evening, and a stool sample was pending. The next morning, a contact precautions sign was posted on R39's door, but R39 was observed in the dining room waiting for breakfast at a table with other residents. A CNA stated the morning report did not include that R39 was ill and should not be in the dining room, and the CNA said the contact precautions sign on the door was missed. An ADON later confirmed R39 should have eaten breakfast in the room because R39 was on contact precautions due to loose stools.
Failure to Coordinate Hospice Care and Communicate Resident Status Across Shifts
Penalty
Summary
A deficiency occurred when the facility failed to ensure proper coordination and communication of hospice services for a resident receiving end-of-life care. The hospice registered nurse (HRN) informed a certified nursing assistant (CNA) during the morning shift that the resident was actively passing and should not be gotten out of bed, except in the case of a rally moment. This critical information was not communicated to the subsequent PM or night shift staff. As a result, the resident was gotten out of bed by night shift staff who were unaware of the resident's actively passing status, following the resident's usual routine. The resident in question had multiple diagnoses, including unspecified dementia and a lumbar vertebra fracture, and was under hospice care with an activated power of attorney for healthcare. On the morning in question, the resident exhibited signs of imminent decline, such as mottling, cool extremities, and increased pain during transfers. The hospice nurse had discussed with staff and family the need to focus on comfort measures, discontinue routine medications, and limit interventions to comfort medications as needed. However, the lack of effective communication between shifts led to the resident being transferred out of bed, contrary to the hospice nurse's instructions. Interviews and record reviews revealed that the facility's policy required collaborative communication and immediate notification of significant changes in a resident's condition. Despite this, the shift-to-shift reporting process failed, as the CNA who received the hospice nurse's instructions did not relay the information to the next shift, and the subsequent staff were not informed of the resident's change in status. This breakdown in communication resulted in the resident not receiving care consistent with their end-of-life needs as outlined in the coordinated hospice care plan.
Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
Staff failed to follow the facility's infection prevention and control program by not implementing enhanced barrier precautions (EBP) during high-contact care activities for two residents. For one resident with chronic wounds, a posted EBP sign was observed outside the room, but no PPE cart or gowns were available nearby. A CNA assisted the resident with toileting and transferring while only wearing gloves, and stated that the resident was not on EBP and that the sign only indicated extra precautions were needed. The resident's treatment record confirmed EBP was required due to chronic wounds. For another resident with a history of traumatic subdural hemorrhage, MRSA infection, wounds, and an indwelling catheter, staff were observed preparing to transfer the resident without wearing any PPE, despite an EBP sign posted outside the room. Both the CNA and LPN involved were unsure about the need for PPE, and no gowns were available near the room. The Director of Nursing later confirmed that PPE, including gown and gloves, should be worn during high-contact care for residents on EBP, and that transferring and toileting are considered high-contact activities.
Lack of Qualified Dietary Manager in Facility
Penalty
Summary
The facility failed to designate a qualified individual to serve as the food and nutrition services director, which is a requirement for ensuring proper dietary management. During a kitchen tour, the surveyor interviewed the Dietary Manager (DM-N), who admitted to not having a dietary manager certification. Although DM-N possessed a ServSafe certification, they were not enrolled in an approved dietary manager or food service manager certification course. The Nursing Home Administrator (NHA-A) confirmed that DM-N lacked the necessary certification and acknowledged that the facility was in the process of reviewing potential courses for DM-N and other kitchen staff. The facility's use of a part-time dietitian did not compensate for the absence of a certified dietary manager, potentially affecting all 72 residents in the facility.
Inadequate Staffing Leads to Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, as evidenced by multiple instances of inadequate care. On several occasions, residents activated their call lights for assistance, but staff either turned off the lights without providing help or delayed assistance due to a lack of available personnel. For example, one resident activated their call light multiple times for toileting assistance, but staff turned off the light without providing help, resulting in the resident experiencing incontinence. Another resident requested assistance to bed, but a CNA turned off the call light and left the room without helping, citing the need for a second staff member who was unavailable. The facility's staffing policy was not effectively implemented, as demonstrated by low staffing levels on specific dates, which were attributed to call-ins and no-shows. The facility's staffing calculations indicated a need for more CNAs and RNs than were scheduled, leading to insufficient coverage. Interviews with staff members revealed that staffing shortages were a recurring issue, particularly on weekends and during night shifts, resulting in delayed response times to residents' needs and complaints about inadequate care. Additionally, the facility failed to consistently provide scheduled showers to residents, as evidenced by incomplete documentation and reports from a resident who did not receive the expected number of showers. The Director of Nursing acknowledged the problem and mentioned plans to trial a shower aide. Staff interviews further highlighted concerns about staffing levels, with some staff members indicating that they were responsible for caring for a large number of residents, which compromised the quality of care provided.
Deficiencies in Timely Assistance and Documentation for ADLs
Penalty
Summary
The facility failed to provide timely and consistent assistance with activities of daily living (ADLs) for six residents, leading to multiple deficiencies. Residents R11 and R17 experienced delays in receiving help with transfers, as their call lights were turned off by CNAs without providing the necessary assistance. R11, who required substantial assistance due to conditions such as congestive heart failure and chronic kidney disease, was left waiting despite the availability of a mechanical lift. Similarly, R17, who was dependent on staff for transfers and receiving hospice services, was left unattended in a recliner for an extended period after activating the call light. Resident R50, who had moderate cognitive impairment, activated the call light for an evening snack but did not receive assistance from an LPN who was unfamiliar with the facility's layout. Additionally, R12 and R30 reported lengthy call light response times and inadequate toileting assistance, resulting in incontinence and discomfort. R12, who was not cognitively impaired, described instances of being left on wet bedding and not receiving a bedpan when requested. R30, who also had a high BIMS score, expressed fear of retribution and reported being treated like a second-class citizen due to the lack of timely assistance. Resident R26, who was dependent on staff for showering, did not consistently receive scheduled showers. Documentation for R26's bathing schedule was incomplete and inconsistent, with several missed opportunities for showers or bed baths. The facility's failure to document refusals or provide adequate bathing care was acknowledged by the Director of Nursing, who noted ongoing issues with shower scheduling and documentation. These deficiencies highlight significant lapses in the facility's ability to meet the basic care needs of its residents.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of drugs and biologicals, as observed by surveyors. A medication cart on the 600 wing was found unlocked and unattended, with a cup containing medication on top and a computer screen displaying residents' personal information left open. The LPN responsible for the cart indicated that it was not their usual practice to leave the cart and medication unattended but was called away for an emergency. The Director of Nursing confirmed that staff should lock medication carts and secure computer screens when unattended. Additionally, the medication storage room on the long-term care unit contained expired medications and medical supplies, including acetaminophen suppositories, lidocaine, and various syringes and caps. The RN present was unaware of who was responsible for maintaining the medications and supplies. Furthermore, a discrepancy was noted in the labeling of a medication card for a resident, where the pharmacy label did not match the physician's order. The RN administering the medication confirmed the label was incorrect, and the current order was for a different dosage.
Medication Administration Delays for a Resident
Penalty
Summary
The facility failed to ensure that medications were administered within the ordered timeframe for a resident, identified as R1, among six sampled residents. R1's medications were administered late on multiple occasions, including 7/29/24, 8/2/24, 10/28/24, 10/30/24, and 11/7/24. The facility's Medication Management Program policy requires medications to be administered no more than one hour before or after the designated medication pass time. However, R1's medications were consistently administered outside of this timeframe. R1, who was admitted with diagnoses including traumatic brain injury, chronic skin ulcer, pain, and dysphagia, was cognitively intact with a BIMs score of 15 out of 15. Despite this, R1's medications were administered late due to various reasons, such as an agency nurse arriving late and needing a password reset, a resident in respiratory distress, room moves, and other emergencies. These delays were documented in R1's medical record and were also the subject of a grievance filed by R1's Power of Attorney. Interviews with the Director of Nursing and other staff revealed that the facility faced challenges with medication administration due to staffing issues and emergencies. The DON acknowledged that medication pass had improved with the introduction of Med Techs and nurses to assist with medication administration. However, during the period in question, R1's medications were not administered in a timely manner, leading to the deficiency noted by the surveyor.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was within reach for a resident who was dependent on staff for mobility and other care needs. The resident, who had a traumatic brain injury and was legally blind, relied on staff assistance to access necessary items. During an observation, the resident's call light and phone were found to be out of reach, placed on a nightstand approximately three feet away from the resident's Broda chair. The resident confirmed the inability to reach these items and stated that staff usually clipped the call light to their pants, but it was not done on this occasion. The incident involved an agency CNA who was working in the facility for the first time. The Nursing Home Administrator confirmed that call lights should be within reach of residents. The resident's care plan included instructions for staff to explain the location of the call light and other items, but these instructions were not followed, leading to the deficiency. The surveyor had to request assistance from another CNA to provide the resident with the phone and call light.
Failure to Investigate and Resolve Resident Grievance
Penalty
Summary
The facility failed to ensure a grievance was thoroughly investigated and resolved for a resident who reported missing personal items. The resident, who was cognitively intact with a BIMS score of 15, informed staff about the missing items, which included a purple cat T-shirt and a polka dot blanket, both of sentimental value. Despite the resident's report, the staff did not follow the facility's grievance process, and no grievance form was completed. The resident's complaint was not communicated to the laundry supervisor or the social worker, who was the facility's grievance officer. Interviews with various staff members, including the laundry supervisor, laundry aid, nursing home administrator, and social worker, revealed a lack of awareness and communication regarding the resident's missing items. The laundry staff did not receive any grievance forms, and the nursing home administrator and social worker were unaware of the issue. The facility's policy required that missing items be reported and documented through a grievance form, but this procedure was not followed, leading to a failure in addressing the resident's grievance effectively.
Inadequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for three residents, leading to deficiencies in their care. Resident 67, who was admitted with a stage 2 pressure injury on the right heel, did not have the necessary interventions in place as recommended by the wound care provider. Despite the wound care provider's instructions to leave the wound open to air and avoid wearing a shoe on the right foot, the resident was repeatedly observed wearing shoes without heel boots. The care plan did not reflect these recommendations, and staff were not informed of the necessary interventions. Resident 17 developed a pressure injury from unpadded oxygen tubing, which caused redness and irritation behind the left ear. The care plan did not include an intervention to inspect the skin behind the ears, and staff failed to address the issue despite the resident's complaints. The Director of Nursing acknowledged that staff should have checked the placement of the oxygen tubing and assessed skin integrity every shift, but this was not done. Resident 1, who had a self-determination care plan allowing a urinal to be propped against the scrotal area, was at risk for skin injury. The care plan did not include interventions to monitor or prevent potential skin injury from the urinal placement. Despite family concerns and observations of red marks on the scrotum, staff continued to place the urinal as per the resident's request without adequate monitoring or documentation of skin assessments related to this practice.
Inconsistent Restorative Therapy for Residents
Penalty
Summary
The facility failed to provide appropriate care and services to maintain or improve the range of motion (ROM) for three residents, leading to deficiencies in their care. Resident 14 did not receive restorative therapy as recommended upon discharge from therapy. The staff failed to correctly enter these recommendations into the resident's medical record, resulting in an incorrect Minimum Data Set (MDS) assessment. The resident's care plan did not include the restorative program, and there was no documentation of the program in the medical record. Interviews with the resident and the Occupational Therapist revealed that the exercises were not being performed with staff assistance as intended. Resident 6 also did not consistently receive restorative therapy. The resident's care plan indicated the need for passive and active ROM exercises and splint brace assistance. However, documentation showed significant gaps in charting these activities over several months. Interviews confirmed that staff should consistently document restorative programs, including any refusals, to ensure accurate MDS coding. Resident 7's care plan required passive ROM exercises multiple times a day, but the resident reported that these exercises were not being performed consistently. Documentation reviewed by the surveyor showed numerous missed sessions over several months. The Minimum Data Set Coordinator confirmed that if ROM was not documented, it was not completed for that shift or day, indicating a failure to adhere to the care plan and provide necessary restorative services.
Failure to Prevent UTI Due to Improper Catheter Care
Penalty
Summary
The facility failed to provide necessary care and services to prevent a urinary tract infection (UTI) for a resident who was reviewed for catheter care. The resident, who was receiving hospice services and had diagnoses including chronic kidney disease stage 3 and recurrent hematuria, had a physician order for an indwelling Foley catheter due to acute urine retention. Despite having an order for a privacy bag to be in place every shift, the resident's catheter drainage bag was observed uncovered and placed on the floor, which is against the facility's policy to prevent contamination and catheter-associated urinary tract infections (CAUTI). During the survey, the infection preventionist confirmed that the catheter bag should not be on the floor and should be covered for infection control and privacy. Additionally, a registered nurse verified that the catheter bag was secured to the resident's bed frame but was still uncovered. The Director of Nursing also confirmed that catheter drainage bags should be covered and not in contact with the floor, indicating a lapse in adherence to the facility's catheter care policy.
Failure to Ensure Proper Oxygen Therapy Management
Penalty
Summary
The facility failed to provide necessary care and treatment for a resident requiring oxygen therapy. During an observation, it was noted that the resident's oxygen tubing lacked a date or initials to indicate when it was last changed, contrary to the facility's policy. The resident, who was receiving hospice services, had diagnoses including COPD, CHF, and CKD stage 3, and had a physician order for 1-6 liters per minute of oxygen via nasal cannula. The facility's nursing orders specified that oxygen equipment should be changed weekly during the night shift. However, the Director of Nursing confirmed that the tubing should have been labeled with the date and initials of the staff who changed it, which was not done in this case.
Failure to Meet Resident's Dietary Preferences
Penalty
Summary
The facility failed to consistently meet the dietary preferences of a resident, identified as R276, who had specific dietary needs due to medical conditions. R276 had a history of surgical aftercare on the digestive system, hyperkalemia, protein-calorie malnutrition, and colon cancer. Despite having a BIMS score indicating no cognitive impairment, R276's dietary preferences, which included a dislike for certain foods and a preference for others, were not consistently honored. The resident had difficulty swallowing meats not in thin deli form and required specific food textures and types to accommodate their digestive and swallowing issues. During the survey, it was observed that R276 did not receive meals according to their specified preferences. For instance, R276 was served meatloaf instead of a deli sandwich, and the bread provided was wheat instead of the preferred white bread. Additionally, the resident received foods that were not suitable for their dietary restrictions, such as a banana despite having high potassium levels. The resident expressed frustration with the facility's inability to meet their dietary needs and was unaware of an alternative menu or the option to communicate meal preferences in advance. The Dietary Manager (DM) acknowledged that R276's meal preferences were not entered into the system and were only posted in the kitchen, which did not inform the staff serving from the dining room steam table. The DM had not personally met with R276 and was unaware of the resident's dissatisfaction. The lack of communication and proper documentation of R276's dietary preferences led to the resident receiving inappropriate meals, causing frustration and reliance on family to provide suitable food.
Failure to Post EBP Signage for Resident with Venous Ulcers
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for a resident who was on enhanced barrier precautions (EBP). The resident, identified as R275, was admitted with right lower leg venous ulcers with copious drainage and had diagnoses including chronic venous hypertension with ulcer, inflammation of the right lower extremity, congestive heart failure, and chronic kidney disease. Despite the resident's condition requiring EBP, there was no signage posted outside the resident's room to inform staff of the necessary infection prevention precautions. The deficiency was observed during a survey when it was noted that EBP signage was missing outside the resident's room. Interviews with the Licensed Practical Nurse (LPN) and the Infection Preventionist (IP) confirmed that the signage should have been posted to alert staff of the precautions needed. The Director of Nursing (DON) also verified that EBP should be assigned for residents with wounds, and acknowledged the absence of signage outside the resident's room.
Medication Administration and Handling Deficiencies
Penalty
Summary
The facility failed to ensure the accurate administration of medication for three residents, as observed during a medication pass. Specifically, medications for residents R2, R6, and R7 were administered late, beyond the one-hour window allowed by the facility's policy. For instance, R2's medications, scheduled for 8:00 AM, were administered at 9:16 AM, and R6's medications, also scheduled for 8:00 AM, were administered at 9:20 AM. Similarly, R7's medications were administered at 10:00 AM, well past the scheduled time. Additionally, the facility did not adhere to safe handling practices for drugs and biologicals. During the medication pass, RN-E was observed dropping R4's aspirin on the floor and disposing of it in the garbage instead of the designated Drug Buster container. Furthermore, RN-E failed to administer R4's carvedilol as ordered. MT-J was also observed improperly disposing of R7's sertraline tablet in a Sharps container after the resident refused it. The surveyor noted a security lapse when a medication cart was left unlocked and unattended in the hallway, with residents nearby. MT-J acknowledged forgetting to lock the cart, which is against the facility's policy. Interviews with RN-E and the Director of Nursing confirmed that medications administered after the designated time are considered late, and wasted medications should be discarded in a Drug Buster.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify a physician of a significant change in condition for a resident, identified as R3, who experienced a substantial weight loss. R3, who had diagnoses including multiple sclerosis, femur fracture, atrial fibrillation, and cognitive communication deficit, was admitted to the facility and had a treatment order for weekly weights. The resident's Minimum Data Set (MDS) assessment indicated intact cognition, and R3 was responsible for their healthcare decisions. Between April 8 and April 15, 2024, R3's weight dropped from 172.6 pounds to 160.8 pounds, resulting in an 8.11% weight loss, which was significant according to the facility's policy. Despite the facility's policy requiring notification of the physician for a 5% or more weight change in one month, R3's physician was not informed of the weight loss. The Director of Nursing (DON) confirmed that the physician was not notified because R3 was discharged, but acknowledged that a reweight and notification should have been completed per the facility's policy. This oversight was identified during a surveyor's review of R3's medical record and interviews with the DON.
Failure to Document and Resolve Grievances
Penalty
Summary
The facility failed to ensure that grievances submitted by a resident's representative were documented, investigated, and resolved. The resident's representative submitted multiple grievances via email and phone over several months concerning the care of the resident, including issues with unsanitary conditions, improper use of medical equipment, and late medication administration. Despite these submissions, the facility did not document these grievances in their grievance log, nor did they conduct thorough investigations or provide resolutions. Interviews with the Director of Nursing and the Nursing Home Administrator revealed that while corrective actions were claimed to have been taken, there was no documentation to support these actions or any follow-up communication with the resident's representative. The facility's grievance policy requires that all grievances be documented, investigated, and resolved with a written decision, but this process was not followed, leading to a deficiency in handling the grievances appropriately.
Failure to Report Resident Altercation
Penalty
Summary
The report identifies a deficiency in the facility's handling of a resident-to-resident physical altercation involving two residents, both diagnosed with vascular dementia and severely impaired cognition. The incident occurred in a lounge area where one resident kicked and struck the other, prompting a staff member to separate them. However, the staff member, a CNA, did not follow the facility's policy of immediately reporting the altercation to a nurse or the Nursing Home Administrator. The CNA was unsure of the proper steps to take during such incidents and could not recall notifying a specific nurse. Interviews with the nursing staff, including LPNs and RNs on duty, revealed that none were informed of the altercation. The Nursing Home Administrator and Director of Nursing were also unaware of the incident until informed by the surveyor. The facility's policy requires immediate reporting of such incidents to ensure resident safety and compliance with state regulations. The failure to report the altercation promptly resulted in a delay in notifying the appropriate authorities, highlighting a breakdown in communication and adherence to established procedures.
Failure to Provide Appropriate ROM Care for Resident
Penalty
Summary
The facility failed to provide appropriate care for a resident, identified as R2, to maintain and/or improve range of motion (ROM) and mobility. R2, who was admitted with diagnoses including cerebral infarction, hemiplegia, hemiparesis, congestive heart failure, and chronic kidney disease, had physician orders for a hand splint and passive range of motion (PROM) exercises. However, the hand splint was not included in R2's care plan, and PROM was not completed as ordered nor included in the care plan. During an interview, R2 reported that therapy was discontinued due to lack of progress, and staff no longer provided daily PROM or assistance with the hand splint. The surveyor's review of R2's Treatment Administration Record (TAR) confirmed that the PROM order was not documented, and the care plan did not address R2's hemiparesis or restorative care needs. Interviews with staff, including a Certified Nursing Assistant (CNA) and a Registered Nurse (RN), revealed a lack of awareness and inconsistency in the application of the hand splint and PROM exercises. The Director of Nursing (DON) verified the omission in the care plan and acknowledged the expectation for restorative care to be included in the care plan.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 547 citations issued within 25 miles in the last 12 months — including the 13 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Slinger
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cedar Lake Health And Rehab Center | 6 mi | ★★★★★ | 13 | 0 |
| Complete Care At Germantown | 8.7 mi | ★★★★★ | 1 | 0 |
| Lasata Care Center | 10.2 mi | ★★★★★ | 8 | 0 |
| Cedarburg Health Services | 10.2 mi | ★★★★★ | 0 | 0 |
| Samaritan Nursing And Rehab | 12.3 mi | ★★★★★ | 44 | 3 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.