Pavilion At Glacier Valley

Inspection findings

1. Jun 11, 2026 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0689 Quality of Life and Care Deficiencies

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

     Corrected Jun 25, 2026 · CMS health inspection

   • Not serious Scope/severity C Complaint

     F0732 Nursing and Physician Services Deficiencies

     Post nurse staffing information every day.

     Corrected Jul 1, 2026 · CMS health inspection

2. Feb 17, 2026 Health · 13 findings
   • Not serious Scope/severity D Complaint

     F0580 Resident Rights Deficiencies

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

     Corrected Mar 12, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0656 Resident Assessment and Care Planning Deficiencies

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

     Corrected Mar 12, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0684 Quality of Life and Care Deficiencies

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

     Corrected Mar 12, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0803 Nutrition and Dietary Deficiencies

     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.

     Corrected Mar 12, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0806 Nutrition and Dietary Deficiencies

     Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

     Corrected Mar 12, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Mar 12, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Mar 12, 2026 · CMS health inspection

   • Not serious Scope/severity E

     K0293 Egress Deficiencies

     Have properly located and lighted "Exit" signs.

     Corrected Mar 11, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Mar 24, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Mar 11, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Mar 11, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0781 Miscellaneous Deficiencies

     Have restrictions on the use of portable space heaters.

     Corrected Mar 12, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Mar 24, 2026 · CMS fire safety

3. Oct 8, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0849 Administration Deficiencies

     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 Dec 5, 2025 · CMS health inspection

4. Aug 8, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Aug 29, 2025 · CMS health inspection

5. Nov 12, 2024 Fire Safety · 21 findings
   • Not serious Scope/severity F

     E0004 Emergency Preparedness Deficiencies

     Develop and maintain an Emergency Preparedness Program (EP).

     Corrected Dec 3, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0013 Emergency Preparedness Deficiencies

     Develop Emergency Preparedness policies and procedures.

     Corrected Dec 3, 2024 · CMS fire safety

   • Not serious Scope/severity D

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Dec 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0585 Resident Rights Deficiencies

     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 Dec 6, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0677 Quality of Life and Care Deficiencies

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

     Corrected Dec 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0686 Quality of Life and Care Deficiencies

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

     Corrected Dec 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0688 Quality of Life and Care Deficiencies

     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 Dec 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0690 Quality of Life and Care Deficiencies

     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 Dec 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

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

     Corrected Dec 6, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0725 Nursing and Physician Services Deficiencies

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

     Corrected Dec 6, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0755 Pharmacy Service Deficiencies

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

     Corrected Dec 6, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0761 Pharmacy Service Deficiencies

     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 Dec 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0800 Nutrition and Dietary Deficiencies

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

     Corrected Dec 6, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0801 Nutrition and Dietary Deficiencies

     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 Dec 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Dec 6, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

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

     Corrected Dec 6, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

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

     Corrected Dec 2, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Dec 12, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Dec 6, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0761 Miscellaneous Deficiencies

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

     Corrected Nov 21, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0925 Gas, Vacuum, and Electrical Systems Deficiencies

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

     Corrected Dec 5, 2024 · CMS fire safety

6. Jul 10, 2024 Health · 5 findings
   • Not serious Scope/severity D Complaint

     F0580 Resident Rights Deficiencies

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

     Corrected Aug 5, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0585 Resident Rights Deficiencies

     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 Aug 5, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

     Corrected Aug 5, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0688 Quality of Life and Care Deficiencies

     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 Aug 5, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0755 Pharmacy Service Deficiencies

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

     Corrected Aug 5, 2024 · CMS health inspection

7. Jan 16, 2024 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0688 Quality of Life and Care Deficiencies

     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 Feb 5, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0755 Pharmacy Service Deficiencies

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

     Corrected Feb 5, 2024 · CMS health inspection

8. Dec 13, 2023 Health · 15 findings
   • Not serious Scope/severity D

     F0551 Resident Rights Deficiencies

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

     Corrected Jan 5, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Jan 8, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0640 Resident Assessment and Care Planning Deficiencies

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

     Corrected Jan 8, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Jan 8, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0690 Quality of Life and Care Deficiencies

     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 Jan 8, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0712 Nursing and Physician Services Deficiencies

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

     Corrected Dec 18, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0757 Pharmacy Service Deficiencies

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

     Corrected Jan 5, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Jan 5, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jan 8, 2024 · CMS health inspection

   • Not serious Scope/severity D

     K0222 Egress Deficiencies

     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 Dec 14, 2023 · CMS fire safety

   • Not serious Scope/severity C

     K0345 Smoke Deficiencies

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

     Corrected Dec 14, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Dec 14, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0711 Miscellaneous Deficiencies

     Provide a written emergency evacuation plan.

     Corrected Dec 14, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0908 Gas, Vacuum, and Electrical Systems Deficiencies

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

     Corrected Jan 4, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Dec 15, 2023 · CMS fire safety

9. Oct 4, 2023 Health · 6 findings
   • Not serious Scope/severity D Complaint

     F0553 Resident Rights Deficiencies

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

     Corrected Oct 27, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

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

     Corrected Oct 27, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0684 Quality of Life and Care Deficiencies

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

     Corrected Oct 27, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0689 Quality of Life and Care Deficiencies

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

     Corrected Oct 27, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0755 Pharmacy Service Deficiencies

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

     Corrected Oct 27, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0758 Pharmacy Service Deficiencies

     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 Oct 27, 2023 · CMS health inspection

Owners and managers (as published by CMS)

• GORDON, DAWN — w-2 managing employee, NOT APPLICABLE, since 06/26/2017
• GORDON, DAWN — corporate officer, NOT APPLICABLE, since 06/26/2017
• THI OF WISCONSIN, LLC — 5% or greater direct ownership interest, 100%, since 08/30/2003