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

Chain footprint

69 facilities

Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars

Changed ownership

Within the last 12 months

Family council

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.80

Registered nurse staffing · state 0.97 · national 0.68

LPN hours / resident day

0.67

Licensed practical nurse staffing · state 0.64 · national 0.87

Aide hours / resident day

1.98

Nurse aide staffing · state 2.59 · national 2.35

Total nurse hours

3.45

All reported nurse hours · state 4.20 · national 3.89

Licensed hours

1.47

RN + LPN hours · state 1.60 · national 1.54

Weekend hours

3.09

Weekend nurse staffing · state 3.72 · national 3.43

Weekend RN hours

0.42

Weekend registered nurse coverage · state 0.66 · national 0.47

Physical therapist

0.07

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.76

CMS adjusted RN staffing hours

Adjusted total hours

3.29

CMS adjusted total nurse staffing hours

Case-mix index

1.44

Higher values indicate more complex resident acuity

RN turnover

15%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

43%

Annual nurse turnover · state 48% · national 46%

SNF VBP

Value-based purchasing

Program rank

8,497

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

26.56

Composite VBP score used to determine payment impact.

Payment multiplier

0.9842

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

3.43

Baseline 16.65% · Performance 19.84% · Measure score 3.43 · Achievement 3.43 · Improvement 0

Healthcare-associated infections

3.19

Baseline 7.10% · Performance 6.88% · Measure score 3.19 · Achievement 3.19 · Improvement 0.55

Total nurse turnover

4.01

Baseline 56.63% · Performance 47.30% · Measure score 4.01 · Achievement 4.01 · Improvement 2.44

Adjusted total nurse staffing

Baseline 3.18 hours · Performance 2.88 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	13.98%	10.72% 3.3 pts worse	Worse than the National Rate · Eligible stays 211 · Observed rate 19.43% · Lower 95% interval 11.44%
Discharge to community	63.62%	50.57% 13 pts better	Better than the National Rate · Eligible stays 163 · Observed rate 57.06% · Lower 95% interval 55.55%
Medicare spending per beneficiary	0.96	1.02 0.1 pts better
Drug regimen review with follow-up	96.59%	95.27% 1.3 pts better	Numerator 85 · Denominator 88
Falls with major injury	1.14%	0.77% 0.4 pts worse	Numerator 1 · Denominator 88
Discharge self-care score	34.85%	53.69% 18.8 pts worse	Numerator 23 · Denominator 66
Discharge mobility score	18.18%	50.94% 32.8 pts worse	Numerator 12 · Denominator 66
Pressure ulcers or injuries, new or worsened	5.68%	2.29% 3.4 pts worse	Numerator 5 · Denominator 88 · Adjusted rate 9.61%
Healthcare-associated infections requiring hospitalization	6.88%	7.12% 0.2 pts better	No Different than the National Rate · Eligible stays 102 · Observed rate 6.86% · Lower 95% interval 4.09%
Staff COVID-19 vaccination coverage	2.13%	8.2% 6.1 pts worse	Numerator 2 · Denominator 94
Staff flu vaccination coverage	81.05%	42% 39 pts better	Numerator 77 · Denominator 95
Discharge function score	30.3%	56.45% 26.2 pts worse	Numerator 20 · Denominator 66
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 28 · Denominator 28
Transfer of health information to patient	94.87%	96.28% 1.4 pts worse	Numerator 37 · Denominator 39
Resident COVID-19 vaccinations up to date	48.98%	25.2% 23.8 pts better	Numerator 24 · Denominator 49

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 · Adjusted 2.3 · Observed 3.5 · Expected 2.9 · Used in QM five-star
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 · Adjusted 1.2 · Observed 1.6 · Expected 2.3 · Used in QM five-star
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 · Q1 89.1% · Q2 93.3% · Q3 92.9% · Q4 96.3% · 4Q avg 92.7%
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 · 4Q avg 100.0%
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 · Q1 4.7% · Q2 5.0% · Q3 1.8% · Q4 1.9% · 4Q avg 3.4% · Used in QM five-star
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 · Q1 0.0% · Q2 1.9% · Q3 1.9% · Q4 4.2% · 4Q avg 1.9%
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 · Q1 0.0% · Q2 2.2% · Q3 4.3% · Q4 6.4% · 4Q avg 3.2%
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 · Q1 8.2% · Q2 10.6% · Q3 15.2% · Q4 10.2% · 4Q avg 11.0%
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 · Q1 10.3% · Q2 11.4% · Q3 7.3% · Q4 11.9% · 4Q avg 10.2% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
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 · 4Q avg 43.8% · Used in QM five-star
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 · Q1 12.8% · Q2 0.0% · Q3 16.7% · Q4 11.4% · 4Q avg 10.7% · Used in QM five-star
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 · Q1 1.7% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star
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 · Q1 4.8% · Q2 3.4% · Q3 7.1% · Q4 1.9% · 4Q avg 4.3% · Used in QM five-star
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 · Q1 19.4% · Q2 16.5% · Q3 32.2% · Q4 19.7% · 4Q avg 21.6%
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 · Q1 9.9% · Q2 12.8% · Q3 9.1% · Q4 6.5% · 4Q avg 9.7% · Used in QM five-star
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 · Q1 83.0% · Q2 91.0% · Q3 91.8% · Q4 84.4% · 4Q avg 87.7%
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 · Adjusted 8.6% · Observed 8.0% · Expected 10.4% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
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 · 4Q avg 91.4%
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 · Adjusted 19.1% · Observed 18.4% · Expected 22.9% · Used in QM five-star

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