Samaritan Nursing and Rehab: Fatal Fall Monitoring Failure - WI
The medical examiner's report listed the cause of death as a concussion in the setting of Parkinsonism. The manner: accident. Sub-manner: fall. R4 also had a right orbital floor blowout fracture, a history of stroke, and left-sided hemiparesis, a partial paralysis affecting one side of her body. She was on hospice.
Inspectors from the Centers for Medicare and Medicaid Services cited Samaritan Nursing and Rehab with an immediate jeopardy violation, the most serious classification available, following a complaint inspection completed October 16, 2025. The finding: staff failed to properly position R4 given her hemiparesis and failed to monitor and assess her after the fall.
She had been vomiting every single day.
The power of attorney and healthcare representative, identified as POAHC-M, told a surveyor on October 7 that R4 threw up at least once a day from the time of the fall until she died. Staff never reported those vomiting episodes to POAHC-M. Instead, POAHC-M was the one reporting them to staff, walking in during visits and telling the facility what was happening to their own resident. POAHC-M submitted a grievance. As of the interview date, no one from the facility had responded.
A family concern report submitted September 2 laid out what happened on August 27. Around noon, R4 vomited on her clothes during a family visit. Family asked staff to change her. When other family members arrived at 5:30 that evening, R4 was still wearing the same clothes.
The Director of Nursing, identified as DON-B, investigated the grievance. She interviewed AM shift staff. They said they didn't know R4 had vomited. DON-B wrote up her findings and closed the investigation.
She never interviewed PM shift staff.
When a surveyor asked DON-B about this directly on October 8, DON-B confirmed it. She had not interviewed the afternoon and evening staff who were on duty when the second set of family members arrived at 5:30 to find R4 still sitting in soiled clothes. DON-B told the surveyor she did not have evidence that R4 had vomited or experienced a change in condition. The Vice President of Skilled Services, identified as VPS-K, said physician notification wasn't necessary because there was no change in condition.
The neurological checks tell a different story about how carefully the facility was watching R4 after her fall.
A registered nurse coordinator identified as RNC-D told surveyors that neurological checks and a Brief Interview for Mental Status assessment had been completed and showed no change. But when surveyors looked at the actual documentation, they found something: a line drawn through the neurological checks scheduled for the PM shift on August 28, the night before R4 died. RNC-D said she was unsure why the line was there. She verified the checks should have been completed.
They weren't documented as completed. The line was just there.
The medical examiner, identified as ME-E, completed a death investigation after R4 died. ME-E spoke with R4's family and with hospice staff. A post-mortem CT scan was performed on September 3 and showed no signs of bleeding. ME-E reviewed the fall documentation, the hospice notes, and R4's medical record before concluding that the death was an accident resulting from the fall. The death certificate listed the concussion, the blowout fracture, and the history of stroke as the constellation of conditions that killed her.
The immediate jeopardy finding centered on two failures that the inspection report treats as connected: the failure to properly position a resident with left-sided hemiparesis, and the failure to monitor and assess her after the fall. For a resident with paralysis on one side of her body, positioning in bed is not routine comfort care. It directly affects her ability to stay safe, to breathe, to avoid aspiration if she vomits. The inspection report states those failures created a reasonable likelihood of serious harm or injury.
R4 vomited every day. Nobody called the physician. Nobody called POAHC-M. The PM shift was never asked what they knew.
Samaritan removed the immediate jeopardy designation on October 12, four days before the inspection closed. The deficiency did not disappear. It dropped to a lower scope and severity level, classified as potential for more than minimal harm in an isolated case, meaning the facility was still in the process of fixing what went wrong when inspectors completed their work.
The facility's corrective plan included reviewing and updating care plans for residents with hemiparesis and fall-related mobility issues, meeting with hospice staff to establish real-time communication about changes in condition, and requiring that hospice staff notify the director of nursing or a designee before leaving the building after any such change. Staff were educated on bed mobility, post-fall assessments, and recognizing changes in condition before their next scheduled shifts. Competency checks on bed mobility and change-in-condition protocols were set to run for four weeks, with immediate additional training whenever a gap was identified.
Those are the steps the facility said it would take going forward.
What they don't address is the investigation that already happened and stopped short. DON-B reviewed the August 27 schedule. She interviewed AM shift staff. She found no evidence of vomiting. She concluded there was no change in condition. She did not ask the people who were there at 5:30 in the evening, when a family member arrived and found R4 in the same vomit-stained clothes she had been wearing since noon.
POAHC-M filed a grievance on September 2. More than five weeks later, when a surveyor called on October 7, POAHC-M had still not heard back from the facility.
POAHC-M was at the facility on August 30 when R4 vomited for what turned out to be the last time. She tried to help. She realized R4 had stopped breathing. She called for help.
The medical examiner ruled the fall killed her.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 24, 2026 · Our methodology
Samaritan Nursing and Rehab in West Bend, WI was cited for violations during a health inspection on October 16, 2025.
The medical examiner's report listed the cause of death as a concussion in the setting of Parkinsonism.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.