Slinger, WI

Pavilion at Glacier Valley

2-star overall rating with 2-star inspections with 14 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle

1900 American Eagle Drive, Slinger, WI

(262) 297-6300

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

106

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Fundamental Healthcare

Operator or chain grouping

Approved since

1989-11-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.80

Registered nurse staffing

LPN hours / resident day

0.67

Licensed practical nurse staffing

Aide hours / resident day

1.98

Nurse aide staffing

Weekend hours

3.09

Weekend nurse staffing

RN turnover

15%

Annual RN turnover

Total nurse turnover

43%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.3	1.6 0.7 pts worse	1.9 0.4 pts worse	Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days	1.2	2.2 1 pts better	1.8 0.6 pts better	Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	92.7%	95.7% 3 pts worse	93.4% 0.7 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	95.0% 5 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury	3.4%	3.2% 0.2 pts worse	3.3% 0.1 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms	1.9%	5.0% 3.1 pts better	11.4% 9.5 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight	3.2%	4.9% 1.7 pts better	5.4% 2.2 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication	11.0%	16.6% 5.6 pts better	19.6% 8.6 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication	10.2%	16.7% 6.5 pts better	16.7% 6.5 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose ability to walk independently worsened	43.8%	21.1% 22.7 pts worse	16.3% 27.5 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased	10.7%	17.3% 6.6 pts better	14.9% 4.2 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.9%	2.3% 1.4 pts better	1.0% 0.1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection	4.3%	3.0% 1.3 pts worse	1.7% 2.6 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	21.6%	25.5% 3.9 pts better	19.8% 1.8 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers	9.7%	5.5% 4.2 pts worse	5.1% 4.6 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	87.7%	86.8% 0.9 pts better	81.7% 6 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit	8.6%	15.0% 6.4 pts better	12.0% 3.4 pts better	Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.3% 1.3 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	91.4%	82.2% 9.2 pts better	79.7% 11.7 pts better	Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission	19.1%	22.7% 3.6 pts better	23.9% 4.8 pts better	Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-11-12 · Fire 2024-11-12

14 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

8 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2023-12-13 · Fire 2023-12-13

15 health deficiencies

Top issue: Pharmacy Service (4 deficiencies)

6 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 3 Health 2022-10-11 · Fire 2022-10-11

27 health deficiencies

Top issue: Quality of Life and Care (9 deficiencies)

7 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-11-12

E13 · Emergency Preparedness Deficiencies

Fire Safety

Develop Emergency Preparedness policies and procedures.

Corrected 2024-12-03

F · Potential for more than minimal harm 2024-11-12

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2024-12-03

F · Potential for more than minimal harm 2024-11-12

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-12-02

F · Potential for more than minimal harm 2024-11-12

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-12-12

E · Potential for more than minimal harm 2024-11-12

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2024-12-06

E · Potential for more than minimal harm 2024-11-12

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-12-06

E · Potential for more than minimal harm 2024-11-12

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2024-11-21

E · Potential for more than minimal harm 2024-11-12

K925 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that sources of ignition are removed from patients receiving respiratory therapy.

Corrected 2024-12-05

F · Potential for more than minimal harm 2023-12-13

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2023-12-14

E · Potential for more than minimal harm 2023-12-13

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-12-14

E · Potential for more than minimal harm 2023-12-13

K908 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.

Corrected 2024-01-04

E · Potential for more than minimal harm 2023-12-13

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2023-12-15

D · Potential for more than minimal harm 2023-12-13

K222 · Egress Deficiencies

Fire Safety

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.

Corrected 2023-12-14

C · Minimal harm 2023-12-13

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-12-14

F · Potential for more than minimal harm 2022-10-11

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2022-10-27

F · Potential for more than minimal harm 2022-10-11

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2022-11-04

F · Potential for more than minimal harm 2022-10-11

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2022-11-04

E · Potential for more than minimal harm 2022-10-11

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2022-10-27

E · Potential for more than minimal harm 2022-10-11

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2022-10-18

D · Potential for more than minimal harm 2022-10-11

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Corrected 2022-10-18

D · Potential for more than minimal harm 2022-10-11

K919 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the use of electrical equipment.

Corrected 2022-10-18

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-10-08

F849 · Administration Deficiencies

Health

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.

Corrected 2025-12-05

D · Potential for more than minimal harm 2025-08-08

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-08-29

F · Potential for more than minimal harm 2024-11-12

F801 · Nutrition and Dietary Deficiencies

Health

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.

Corrected 2024-12-06

E · Potential for more than minimal harm 2024-11-12

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2024-12-06

E · Potential for more than minimal harm 2024-11-12

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2024-12-06

E · Potential for more than minimal harm 2024-11-12

F761 · Pharmacy Service Deficiencies

Health

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.

Corrected 2024-12-06

D · Potential for more than minimal harm 2024-11-12

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2024-12-06

D · Potential for more than minimal harm 2024-11-12

F585 · Resident Rights Deficiencies

Health

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.

Corrected 2024-12-06

D · Potential for more than minimal harm 2024-11-12

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-12-06

D · Potential for more than minimal harm 2024-11-12

F688 · Quality of Life and Care Deficiencies

Health

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.

Corrected 2024-12-06

D · Potential for more than minimal harm 2024-11-12

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2024-12-06

D · Potential for more than minimal harm 2024-11-12

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-12-06

D · Potential for more than minimal harm 2024-11-12

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-12-06

D · Potential for more than minimal harm 2024-11-12

F800 · Nutrition and Dietary Deficiencies

Health

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Corrected 2024-12-06

D · Potential for more than minimal harm 2024-11-12

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-12-06

E · Potential for more than minimal harm 2024-07-10

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-08-05

D · Potential for more than minimal harm 2024-07-10

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2024-08-05

D · Potential for more than minimal harm 2024-07-10

F585 · Resident Rights Deficiencies

Health

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.

Corrected 2024-08-05

D · Potential for more than minimal harm 2024-07-10

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-08-05

D · Potential for more than minimal harm 2024-07-10

F688 · Quality of Life and Care Deficiencies

Health

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.

Corrected 2024-08-05

D · Potential for more than minimal harm 2024-01-16

F688 · Quality of Life and Care Deficiencies

Health

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.

Corrected 2024-02-05

D · Potential for more than minimal harm 2024-01-16

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-02-05

E · Potential for more than minimal harm 2023-12-13

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-01-08

D · Potential for more than minimal harm 2023-12-13

F551 · Resident Rights Deficiencies

Health

Give the resident's representative the ability to exercise the resident's rights.

Corrected 2024-01-05

D · Potential for more than minimal harm 2023-12-13

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-01-08

D · Potential for more than minimal harm 2023-12-13

F640 · Resident Assessment and Care Planning Deficiencies

Health

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Corrected 2024-01-08

D · Potential for more than minimal harm 2023-12-13

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-01-08

D · Potential for more than minimal harm 2023-12-13

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2024-01-08

D · Potential for more than minimal harm 2023-12-13

F712 · Nursing and Physician Services Deficiencies

Health

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Corrected 2023-12-18

D · Potential for more than minimal harm 2023-12-13

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2024-01-05

D · Potential for more than minimal harm 2023-12-13

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-01-05

D · Potential for more than minimal harm 2023-10-04

F553 · Resident Rights Deficiencies

Health

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Corrected 2023-10-27

D · Potential for more than minimal harm 2023-10-04

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2023-10-27

D · Potential for more than minimal harm 2023-10-04

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-10-27

D · Potential for more than minimal harm 2023-10-04

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-10-27

D · Potential for more than minimal harm 2023-10-04

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2023-10-27

D · Potential for more than minimal harm 2023-10-04

F758 · Pharmacy Service Deficiencies

Health

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.

Corrected 2023-10-27