The resident, identified only as R1 in inspection records, had an oxygen concentrator at their bedside when inspectors arrived on October 7. When asked if they needed oxygen, the resident said they didn't know. They showed no signs of shortness of breath during the interview.
The facility's medical records contained no physician order for oxygen therapy. Progress notes indicated the resident required oxygen after a respiratory status change on September 13, but staff had been providing the treatment without proper authorization for nearly a month.
Director of Nursing B told inspectors the resident had no oxygen order or care plan addressing oxygen use. She scrambled to locate documentation during the survey, finding a hospice provider's order dated September 17 that authorized "1-5 liters per minute continuous as needed for dyspnea." That order wasn't entered into the resident's medical record until October 7 — the day inspectors questioned its absence.
A second order surfaced the following day, supposedly dated September 13, authorizing emergency oxygen at 2 liters per minute every four hours as needed. The director confirmed this order was also entered on October 7, during the federal inspection.
The resident suffered from multiple serious conditions including malignant bladder cancer, secondary bone cancer, toxic brain damage, and osteoporosis with fractures. A September assessment showed moderate cognitive impairment, with a mental status score of 10 out of 15. The resident had an activated power of attorney for healthcare decisions.
Certified Nursing Assistant G was unsure whether the resident used oxygen and said oxygen therapy wasn't included on the resident's CNA care plan. Registered Nurse F confirmed the resident had an oxygen concentrator but acknowledged there was no order or care plan for its use.
The facility provided inspectors with an undated oxygen policy that addressed safety and fire prevention but contained no clinical guidelines for oxygen therapy administration. The director of nursing said this was their only oxygen-related policy.
Oxygen therapy requires careful medical supervision. Too little oxygen can worsen breathing difficulties and organ function. Too much can suppress breathing reflexes in some patients or increase fire risks. Federal regulations require physician orders for all treatments and comprehensive care plans addressing each resident's specific needs.
The inspection occurred after a complaint was filed about the facility. Inspectors classified the violation as causing minimal harm or potential for actual harm to residents.
The resident's case illustrates broader concerns about medication and treatment oversight in nursing homes. Without proper orders and care plans, staff cannot ensure appropriate dosing, monitoring, or safety precautions. The timing of the missing documentation — entered only when inspectors questioned its absence — suggests the facility may have been providing unauthorized treatment for weeks.
Samaritan Nursing and Rehab operates at 531 E Washington Street in West Bend. The facility must submit a plan of correction to state and federal regulators detailing how it will prevent similar violations.
The resident remains at the facility with their oxygen concentrator, now with documentation that should have existed from the start of treatment.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Samaritan Nursing and Rehab from 2025-10-16 including all violations, facility responses, and corrective action plans.