Samaritan Nursing and Rehab: Oxygen Order Missing - WI
The patient, identified in inspection records only as Resident 1, was admitted to the facility with bladder cancer that had spread to the bone, toxic encephalopathy, and osteoporosis with pathological fractures. A hospice provider was involved in the resident's care. Progress notes in the medical record showed the resident had experienced a change in respiratory status on September 13, 2025, and required oxygen after that.
The concentrator was in the room. The order was not.
When a state surveyor arrived on October 7 and sat down with the resident at 9:45 in the morning, the machine was right there beside the bed. The surveyor asked whether the resident needed oxygen. The resident said they didn't know. The resident did not appear short of breath during the conversation.
A certified nursing assistant interviewed later that morning said she wasn't sure whether the resident used oxygen and confirmed it wasn't listed anywhere on her care plan. A registered nurse, interviewed just before noon, verified the same thing: concentrator in the room, no order, nothing in the care plan. The Director of Nursing, DON-B, said the same when asked at 1:15 that afternoon.
Then DON-B found something. A hospice provider had written an oxygen order on September 17, more than two weeks before the inspection, directing staff to administer one to five liters per minute as needed for shortness of breath. DON-B entered that order into the resident's medical record that same afternoon, while the surveyor was still on-site.
The next morning, the surveyor reviewed the record again and found a second order, this one dated September 13, instructing staff to apply oxygen at two liters per minute in an emergency, obtain vital signs, and notify a physician if continuous oxygen was needed. DON-B confirmed that order had also been entered on October 7, the day the surveyor arrived.
Both orders existed, somewhere, before the inspection. Neither had made it into the medical record the facility's own staff were working from.
The resident had moderate cognitive impairment, with a score of 10 out of 15 on a standardized mental status assessment. An activated power of attorney for healthcare was in place. Whether anyone with authority to ask questions on the resident's behalf knew that oxygen therapy was happening without documentation, the inspection report does not say.
When the surveyor asked DON-B for the facility's oxygen policy, DON-B produced a single undated form addressing oxygen safety and fire prevention. DON-B said the facility had no other oxygen policy.
The violation was cited at the minimal harm level. The resident did not appear to be in distress during the inspection, and the report does not describe any documented adverse event tied to the documentation gap. But the resident was receiving hospice care for metastatic cancer, had a documented respiratory event in mid-September, and was using a machine that, for purposes of the facility's own records, had no authorized purpose and no care instructions attached to it for the staff responsible for that person's daily care.
The CNA who tended to the resident each day had nothing in her care plan telling her the resident used oxygen. The nurse who would have responded to a change in the resident's breathing had no standing order to reference. The order that would have guided them had been sitting outside the medical record since September.
It was entered into the system the afternoon someone came to look.
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.
Download the official CMS inspection PDF from Medicare.gov
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 23, 2026 · Our methodology
Samaritan Nursing and Rehab in West Bend, WI was cited for violations during a health inspection on October 16, 2025.
A hospice provider was involved in the resident's care.
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.