Samaritan Nursing and Rehab: Missing Items Unreported - WI
The watch had sentimental value. The family said so explicitly when the facility offered to pay them back for it. They declined the money. They wanted the watch.
The facility looked. Housekeeping searched. Nursing staff searched. Nobody found it. And nobody called police.
That was the finding federal inspectors documented after a complaint inspection completed October 16, 2025. Samaritan, a nursing and rehabilitation facility at 531 E. Washington Street, failed to report two separate allegations of resident property theft to law enforcement or to the state survey agency, as required. The violations were cited at a level of minimal harm or potential for actual harm.
The resident whose watch went missing, identified in inspection records only as R17, had dementia and a neurocognitive disorder with Lewy bodies. A cognitive assessment from August 2025 gave him a score of 1 out of 15, indicating severe impairment. He could not advocate for himself. His healthcare power of attorney, identified as POAHC-U, was the one who noticed the watch was gone.
According to inspection records, R17 had gone to the hospital and returned with the watch. After he died at the facility, POAHC-U went through his belongings. The watch wasn't there.
POAHC-U reported it to the facility's grievance officer on September 24, 2025, roughly two weeks after R17's death. The grievance officer, identified as GO-I, confirmed receiving the complaint. Staff looked. The watch stayed missing. GO-I offered reimbursement. POAHC-U said no.
When the surveyor asked GO-I whether the missing watch should have been reported to law enforcement or the state, GO-I said she wasn't sure. She said the administrator handled those calls.
The administrator, NHA-A, told the surveyor on October 8 that the missing watch wasn't an allegation of misappropriation because POAHC-U hadn't said with certainty it was stolen. POAHC-U had reported it missing but wasn't sure if it was stolen. That uncertainty, the administrator said, was reason enough not to call anyone.
Law enforcement was never notified. The state survey agency was never notified.
The second case involved a resident identified as R1 and a missing iPad. The inspection records don't detail how or when the iPad was reported missing, but they document the administrator's reasoning for not treating it as a theft allegation: the iPad wasn't on R1's official inventory list, and staff didn't remember seeing it. The administrator told the surveyor she didn't believe R1 had an iPad in the facility at all.
No report was made to law enforcement. No report was made to the state.
The pattern across both cases is the same. An item goes missing. The facility investigates internally. The investigation goes nowhere. And the administrator finds a reason, in each instance, why the situation doesn't rise to the level of a formal allegation requiring outside notification. The iPad wasn't on the inventory list. The family wasn't certain the watch was stolen.
What the inspection record doesn't contain is any indication that the facility considered the alternative: that a resident with a cognitive score of 1 out of 15 cannot protect his own property, that a watch brought back from a hospital stay and present at the time of death should be present when a family comes to collect belongings, and that the gap between those two facts is exactly what mandatory reporting obligations exist to address.
POAHC-U declined the money. The watch had sentimental value. It has not been found.
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 25, 2026 · Our methodology
Samaritan Nursing and Rehab in West Bend, WI was cited for violations during a health inspection on October 16, 2025.
The watch had sentimental value.
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.