Samaritan Nursing and Rehab: Fall Care Plan Failures - WI
The inspection, completed November 11, 2025, focused on one resident identified in the report as R5. The falls happened on July 2, July 7, July 23, and October 20, 2025. After each one, staff were supposed to review what happened, determine what interventions made sense, and record them in R5's care plan so everyone providing care would know what precautions to take. None of that happened. The care plan sat unchanged.
The October fall came when R5 reached for something on the ground from bed. R5's call light went on. A handwritten falls checklist followed, the kind of form that exists to make sure nothing gets missed. Item ten on that checklist read: "Add new focus update care plan Actual Fall Occurred." Checked as completed. Item eleven: "Add/update care plan with interventions under Risk for Falls." Also checked as completed.
Neither had been done.
When a surveyor sat down with R5 on November 4, the resident said no bolsters or floor mats had ever been placed next to the bed, though staff did keep the bed in a low position. R5 said a bolster or mat would actually be unwanted, out of concern about tripping on it. R5 also acknowledged self-transferring when the expectation was to wait for staff assistance.
That conversation mattered because it showed something real: a resident with preferences, with a history of falls, with opinions about what felt safe and what didn't. That kind of information belongs in a care plan. It's how the night-shift aide who has never met R5 knows what to expect walking into that room. Without it, each staff member is starting from scratch.
The surveyor also interviewed the facility's Vice President of Clinical Operations, identified in the report as VPCO-D. She described how the process is supposed to work: immediate interventions go in right away, then the interdisciplinary team meets to review the fall, sometimes adjusting those initial interventions and adding new ones. After that review, she said, the care plan gets updated.
She confirmed R5's care plan had not been updated.
That confirmation is worth sitting with. The facility's own top clinical officer acknowledged, on the record, that the process her facility designed, the one that existed specifically to protect residents like R5, had not been followed. Not once. Not after the first fall in July, not after the second five days later, not after the third two weeks after that, and not after the fourth in October.
The deficiency was cited at a level of minimal harm or potential for actual harm, meaning inspectors did not find that R5 had been seriously injured as a direct result of the missing care plan updates. That classification reflects what was documented, not what could have happened on any of those four nights between a fall and a shift change, when a staff member with no updated guidance walked into R5's room.
R5 knew, at least in part, what the risks were. The resident said so directly, acknowledging the habit of self-transferring when help was supposed to be on the way. What R5 didn't have was a care team working from the same current information, with interventions reviewed, agreed upon, and written down where anyone could find them.
The checklist boxes were checked. The care plan stayed blank.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Samaritan Nursing and Rehab from 2025-11-11 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 22, 2026 · Our methodology
Samaritan Nursing and Rehab in West Bend, WI was cited for violations during a health inspection on November 11, 2025.
The inspection, completed November 11, 2025, focused on one resident identified in the report as R5.
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.