Federal inspection record · CMS data as of October 1, 2026
Pavilion at Glacier Valley
1900 American Eagle Drive, Slinger, WI · (262) 297-6300
- Certified beds
- 106
- Residents per day
- 76
- Ownership
- For-Profit
- Chain
- Fundamental Healthcare
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- November 1, 1989
1
How this home got 2 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Wisconsin.
-
Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★2 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Wisconsin homes
Pavilion at Glacier Valley carries 80 inspection points. That is fewer than 39% of Wisconsin's 321 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Wisconsin: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–11 pts
- 4★ 11–37 pts
- 3★ 37–76 pts
- 2★ 76–130.75 pts
- 1★ over 130.75 pts
Bars show every rated home in Wisconsin by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
46 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
No citation on record at the harm or immediate-jeopardy level.
Everything else, by area of care
Quality of Life and Care12E
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Pharmacy Service8E
- E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- D
Ensure that residents are free from significant medication errors.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Resident Rights7D
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- D
Reasonably accommodate the needs and preferences of each resident.
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
- D
Give the resident's representative the ability to exercise the resident's rights.
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Nutrition and Dietary5F
- F
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
- F
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
- D
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Resident Assessment and Care Planning4D
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
- D
Ensure each resident receives an accurate assessment.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Infection Control4E
- D
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
Nursing and Physician Services3E
- C
Post nurse staffing information every day.
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- D
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Freedom from Abuse, Neglect, and Exploitation2D
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Respond appropriately to all alleged violations.
Administration1D
- D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Inspection history
2026-02-17
10 health deficiencies · 6 fire-safety deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
2024-11-12
14 health deficiencies · 8 fire-safety deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2023-12-13
22 health deficiencies · 6 fire-safety deficiencies
Top issue: Pharmacy Service (6 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 3 h 34 min of nursing staff time a day, 37 min of it from a registered nurse.
This home
3 h 34 min
Wisconsin average
4 h 15 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 42% of nursing staff and 31% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine1.3 pts better | 97.3% | 96.0% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine4.4 pts better | 100.0% | 95.6% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury1.2 pts worse | 4.5% | 3.3% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms2.4 pts better | 3.6% | 6.0% | 13.5% |
| Percentage of long-stay residents who lose too much weight0.4 pts better | 4.5% | 4.9% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication8.1 pts better | 8.7% | 16.8% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication5.2 pts better | 10.7% | 15.9% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened12.4 pts worse | 29.4% | 17.0% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased3.2 pts better | 12.6% | 15.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder1.3 pts better | 0.6% | 1.9% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.5 pts worse | 3.2% | 2.7% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence3.7 pts better | 19.9% | 23.6% | 18.3% |
| Percentage of long-stay residents with pressure ulcers0.5 pts worse | 5.4% | 4.9% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine8.5 pts worse | 78.4% | 86.9% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit0.9 pts better | 14.7% | 15.6% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication1.2 pts better | 0.0% | 1.2% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine9.5 pts worse | 72.7% | 82.2% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission2.6 pts worse | 25.1% | 22.5% | 23.4% |
·
Who owns and runs it
3 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Thi Of Wisconsin, LLC | 5% Or Greater Direct Ownership Interest · Organization | 100% | 1 facilities |
| Gordon, Dawn | W-2 Managing Employee · Individual | 0% | 1 facilities |
| Gordon, Dawn | Corporate Officer · Individual | 0% | 1 facilities |
·
Fire safety
20 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke6F
- F
Inspect, test, and maintain automatic sprinkler systems.
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- F
Inspect, test, and maintain automatic sprinkler systems.
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E
Install corridor and hallway doors that block smoke.
- C
Have approved installation, maintenance and testing program for fire alarm systems.
Miscellaneous4F
- F
Have simulated fire drills held at unexpected times.
- D
Have restrictions on the use of portable space heaters.
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- F
Provide a written emergency evacuation plan.
Gas, Vacuum, and Electrical Systems4E
- D
Have proper medical gas storage and administration areas.
- E
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
- E
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
- E
Have proper medical gas storage and administration areas.
Egress2E
- E
Have properly located and lighted "Exit" signs.
- D
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Services2E
- D
Have properly installed electrical wiring and gas equipment.
- E
Have properly installed electrical wiring and gas equipment.
Emergency Preparedness2F
- F
Develop Emergency Preparedness policies and procedures.
- F
Develop and maintain an Emergency Preparedness Program (EP).
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Other homes nearby
-
Cedar Lake Health and Rehab Center
West Bend, WI
★★★★★- Worst citation, 3 yrs
- F
- Nursing / resident / day
- 5 h 13 min
- Fines
- $0
-
Complete Care at Germantown
Germantown, WI · Complete Care
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 3 h 46 min
- Fines
- $0
-
Cedarburg Health Services
Cedarburg, WI · North Shore Healthcare
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 4 h 27 min
- Fines
- $0