Samaritan Nursing And Rehab

F 0755

nursing staff to address the issues and instructed staff to inform DON-B with continued concerns.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Samaritan Nursing and Rehab

531 E Washington St West Bend, WI 53095

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Based on observation, staff interview, and record review, the facility did not ensure drugs and biologicals were stored in accordance with the facility's policy. This practice had the potential to affect more than 4 of

the 67 residents residing in the facility.On 8/26/25. the 400 North medication cart was left unlocked and unattended.Findings include:The facility's Storage of Medications policy, dated 4/2007, indicates: .7.

Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others .On 8/26/25 at 9:23 AM, Surveyor observed agency Registered Nurse (RN)-J leave a medication cart unlocked and unattended with an open computer screen on top of the cart that displayed resident information. The medication cart drawers faced the hallway. Surveyor observed one resident self-propel in a wheelchair in the hallway.On 8/26/25 at 9:23 AM, Surveyor interviewed RN-J who verified the medication cart should not be left unlocked and unattended and the computer should be turned off. RN-J indicated RN-J usually locks the cart but forgot when RN-J went to the kitchen to refill a water jug. On 8/26/25 at 10:54 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated medications carts should be locked when unattended.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Samaritan Nursing and Rehab

531 E Washington St West Bend, WI 53095

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, staff and resident interview, and record review, the facility did not ensure food was served at a palatable, safe, and appetizing temperature for 4 residents (R) (Resident R1, Resident R3, Resident R2 and Resident R4) of 6 sampled residents. This practice had the potential to affect more than 4 of the 67 residents residing in the facility.Resident R1 and Anonymous Person (AP)-E (on behalf of Resident R3) indicated hot and cold foods were not always served at palatable temperatures. Resident R2 and Resident R4 indicated the food was not palatable. During the lunch meal

on 8/25/25, the facility served food that appeared to be burned. During the lunch meal on 8/26/25, food was not held at a palatable temperature.Findings include:The 2022 Federal Food and Drug Administration (FDA) Food Code documents at 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and (C) of this section, time/temperature control for safety food shall be maintained: (1) At 57 Celsius (C) (135 Fahrenheit (F)) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54 degrees C (130 degrees F) or above; or (2) At 5 C (41 F) or less.The temperatures are designed to reduce the risk of foodborne illnesses by ensuring harmful pathogens are destroyed during cooking.On 8/25/25 at 9:58 AM, Surveyor interviewed AP-E who indicated Resident R3 had a soft bite diet, however, the food Resident R3 received was mushy and usually cold. AP-E felt that may be why Resident R3 did not always eat.On 8/25/25 at 12:11 PM, Surveyor observed lunch in the fourth floor dining room. A posted menu indicated the meal was ham steak with baked sweet potato, cauliflower, and fruited gelatin. During lunch, Surveyor observed the following:~ Resident R4 was at a table with 2 other residents.

Surveyor observed staff serve Resident R4's meal and heard Resident R4 indicate the sweet potato was burned. Resident R4 declined to eat the sweet potato. Staff took Resident R4's plate and brought Resident R4 an alternate. Surveyor also overheard Resident R4 state to another resident that the food was terrible.~ Surveyor observed 4 other residents' sweet potatoes and noted the potatoes contained a black peel and edges.~ Resident R3 was served ground ham, mashed cauliflower, and cut up sweet potato. Resident R3 ate approximately half of the meal. (Documentation in Resident R3's medical

record indicated Resident R3 usually ate between 50-75% of meals.)On 8/25/25 at 2:48 PM, Surveyor interviewed Resident R4 who indicated the food was mediocre and institutional tasting.On 8/26/25 at 10:17 AM, Surveyor interviewed Resident R2 who stated the food was gross and not palatable.On 8/26/25 at 12:05 PM, Surveyor observed lunch in the fourth floor dining room. A posted menu indicated the meal was sweet and sour chicken with steamed rice, steamed broccoli, a mini egg roll, and fruit fluff.On 8/26/25 at 12:55 PM, Surveyor asked Dietary Aide (DA)-C to complete holding temperatures in the steam table. Surveyor observed the following temperatures:~ Steamed rice: 91 F~ Sweet and sour chicken: 87 F~ Broccoli: 77 FSurveyor interviewed DA-C who was not aware of minimum holding temperatures or what steps to take if temperatures were below minimum holding temperatures.On 8/26/25 at 2:23 PM, Surveyor interviewed Resident R1 who stated staff put cold food on the same tray and under the same food cover as hot food which made the cold food warm and gross.On 8/26/25 at 12:59 PM, Surveyor interviewed Food Service Director (FSD)-D who stated hot food should be held at 135 F or higher and cold food at 41 F or lower. FSD-D stated staff take holding temperatures prior to serving. FSD-D stated food should be at minimum holding temperatures at the end of meal service, however, minimum holding temperatures were not routinely monitored at the end of meal service. FSD-D stated staff should notify the kitchen if holding temperatures are not at minimum temperatures prior to serving. FSD-D stated there were concerns that the steam rollers were not holding temperatures and maintenance was notified. FSD-D stated it was recommended that the facility replace the steam rollers.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet