Samaritan Nursing and Rehab: Care Order Failures - WI
The resident, identified in inspection records as R2, arrived from the hospital on September 18 with TED hose already on both legs. An orthopedic doctor ordered a switch to double-layer Tubigrips on September 22, after a progress note documented that R2's left lower leg was red and the edema was worse on that side than the right. The next morning, a skilled nursing assessment recorded that R2 still had TED hose in place. The day after that, an advanced practice nurse practitioner's note said the same thing. R2 was sent back to the hospital on September 25 with cellulitis.
Staff also missed R2's daily weights on September 19 and September 24. R2 had an order for daily weights specifically because of water retention from heart failure.
The Director of Nursing, identified as DON-B, confirmed both failures when a surveyor interviewed her on October 8. She verified the missed weights, the missed edema assessments, and the fact that the Tubigrip order was not followed. She said staff should follow care plans and medical orders.
That confirmation did not resolve what inspectors found elsewhere in the building that same week.
A second resident, R8, had atrial fibrillation, CHF, and hypertensive heart and chronic kidney disease. R8 also had a doctor's order for Tubigrips: on in the morning, off in the evening. When a surveyor observed R8 in a wheelchair in R8's room on the afternoon of October 7, R8 was wearing Tubigrips. R8 said staff had put them on that morning but did not remember anyone taking them off at night.
The next morning, at 8:30 AM, R8 was in the dining room. Still wearing Tubigrips. Four minutes later, a certified nursing assistant told the surveyor that R8 had slept in them the night before.
A third resident, R11, had vascular dementia severe enough that a cognitive assessment scored four out of fifteen, and a power of attorney for healthcare had been activated. R11's diagnoses included muscle wasting and atrophy, spinal stenosis, and hypertensive heart disease with heart failure. The same Tubigrip order applied: on in the morning, off at night.
R11's power of attorney told the surveyor that most nights staff do remove the Tubigrips, but some nights they forget. The power of attorney said concerns about proper application and removal had already been raised with the facility before the inspection.
On the morning of October 8, a surveyor found R11 in the bathroom wearing Tubigrips, waiting for assistance. R11 said they had slept in them. The surveyor then interviewed four certified nursing assistants assigned to R11's hallway, one after another, between 8:19 and 8:24 that morning. All four denied putting the Tubigrips on R11 that morning, and all four confirmed the order required removal each evening.
Nobody could account for how the Tubigrips got there.
Compression garments applied overnight on patients with circulatory and cardiac conditions can restrict blood flow in ways the treating physician did not intend, which is why timed removal orders exist. When R2's left leg turned red and the edema worsened, the orthopedic doctor's response was to escalate the compression protocol and change the garment type. Staff continued using the original garment for three more days.
DON-B, when interviewed a second time on October 8, said only that staff should follow medical orders for Tubigrips.
R11's power of attorney had already said that to the facility. The inspection found the same problem still happening.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 8, 2026 · Our methodology
Samaritan Nursing and Rehab in West Bend, WI was cited for violations during a health inspection on October 16, 2025.
The resident, identified in inspection records as R2, arrived from the hospital on September 18 with TED hose already on both legs.
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.