Samaritan Nursing And Rehab
Samaritan Nursing and Rehab in West Bend, WI — inspection on October 16, 2025.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
NHA-A indicated NHA-A did not believe R1 had an iPad in the facility. 2.
From 10/7/25 to 10/8/25,
out of 15 which indicated R17 had severe cognitive impairment. R17 had an activated POAHC
R17's watch was missing.
The facility offered to reimburse the watch, however, POAHC-U declined and indicated the watch had sentimental value.
The grievance investigation did not indicate the facility reported the allegation of misappropriation to law enforcement or the SA.On 10/8/25 at 10:00 AM, Surveyor interviewed POAHC-U who indicated R17 went to the hospital and returned with R17's watch.
After R17 passed at the facility, POAHC-U went through R17's belongings and indicated R17's watch was missing. POAHC-U reported the missing watch to Grievance Officer (GO)-I on 9/24/25.
POAHC-U indicated the facility could not find R17's watch and offered to reimburse POAHC-U.
POAHC-U declined reimbursement and indicated the watch had sentimental value. On 10/8/25 at 11:00 AM, Surveyor interviewed GO-I who verified the facility received a grievance on 9/24/25 that indicated R17's watch was missing. GO-I indicated R17 passed away approximately 2 weeks prior to receipt of the grievance. GO-I notified POAHC-U that housekeeping and nursing staff looked for the watch but couldn't find it. GO-I offered to reimburse POAHC-U, however, POAHC-U decline reimbursement and stated the watch had sentimental value. GO-I was unsure if the missing watch should have been reported to law enforcement or the SA and stated NHA-A notifies law enforcement and the SA when necessary. On 10/8/25 at 1:00 PM, Surveyor interviewed NHA-A who indicated R17's watch was reported missing by POAHC-U two weeks after R17 passed away. NHA-A indicated the missing watch was not an allegation of misappropriation because POAHC-U reported the watch missing but was not sure if it was stolen. NHA-A verified law enforcement and the SA were not notified of the missing watch.
525165 10/16/2025
Samaritan Nursing and Rehab 531 E Washington St West Bend, WI 53095
had sentimental value. On 10/8/25 at 11:00 AM, Surveyor interviewed GO-I who verified a grievance
nursing staff looked for the watch but couldn't find it. GO-I offered to reimburse POAHC-U, however,
not have documentation that other residents and staff were interviewed about the missing watch or other potential missing personal property. On 10/8/25 at 1:00 PM, Surveyor interviewed NHA-A who indicated R17's watch was reported missing by POAHC-U two weeks after R17 passed away. NHA-A verified the facility did not have documentation to verify other residents and staff were interviewed about the missing watch. NHA-A verified a through investigation was not completed for R17's missing watch.
525165 10/16/2025
Samaritan Nursing and Rehab 531 E Washington St West Bend, WI 53095
shift until 9/21/25 (initiated 9/18/25).~ Daily weight due to water retention-CHF every day shift
remove in the evening (initiated 9/21/25).~ Double layer Tubigrips on in the AM and remove at
morning and at bedtime (initiated 9/22/25).Surveyor noted R2 was admitted to the facility from the hospital on 9/18/25 with TED hose in place; however, R2 did not have an order for TED hose until 9/21/25. ~ A progress note, dated 9/22/25 at 4:17 PM, indicated R2 had lower extremity edema.
The left side was worse than the right and R2's LLE was red. R2's orthopedic doctor gave an order to switch R2's TED hose to double layer Tubigrips. ~ A Daily Skilled Assessment, dated 9/23/25 at 11:14 AM, indicated R2 had BLE 3+ edema and TED hose in place (instead of Tubigrips which were ordered on 9/22/25). ~ An APNP assessment, dated 9/24/25 at 10:30 AM, indicated R2 had LLE 2+ edema, warm and perfused, with no weight gain.
The note indicated TED hose were still in place.R2 was discharged to the hospital with cellulitis on 9/25/25.On 10/8/25 at 10:19 AM and 12:49 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff should obtain daily weights and document them in the medical record for residents with daily weight orders. DON-B verified there were missed weights and edema assessments for R2. DON-B indicated staff should follow R's care plan and complete daily edema assessments. DON-B also verified R2's Tubigrip order was not followed and indicated staff should follow medical orders for Tubigrips and TED hose.2. On 10/7/25, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] and had diagnoses including atrial fibrillation, CHF, and hypertensive heart and chronic kidney disease with heart failure.
R8's MDS assessment, dated 9/10/25, had a BIMS score of 11 out of 15 which indicated R8 had moderate cognitive impairment. R8 had an activated Power of Attorney for Healthcare (POAHC).R8's medical record contained an order for Tubigrips to be applied in the morning and removed in the evening. On 10/7/25 at 3:26 PM, Surveyor observed R8 in a wheelchair in R8's room wearing Tubigrips. R8 indicated staff put the Tubigrips on in the morning but did not recall staff taking them off at night.On 10/8/25 at 8:30 AM, Surveyor observed R8 in the dining room wearing Tubigrips. On 10/8/25 at 8:34 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-O who indicated R8 slept in the Tubigrips last evening. CNA-O indicated Tubigrips should be applied in the morning and removed in the evening. 5. On 10/7/25, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] and had diagnoses including muscle wasting and atrophy, spinal stenosis, vascular dementia, and hypertensive heart disease with heart failure. R11's MDS assessment, dated 9/8/25, had a BIMS score of 4 out of 15 which indicated R11 had severe cognitive impairment. R11 had an activated POAHC.R11's medical record contained an order for Tubigrips to be applied in the morning and removed in the evening. On 10/7/25 at 3:58 PM, Surveyor observed in R11's room wearing Tubigrips.
Surveyor interviewed R11 and R11's POAHC (POAHC-P) who indicated most nights staff remove R11's Tubi grips, however, some nights staff forget to remove them. POAHC-P indicated concerns were expressed to the facility regarding proper Tubigrip application and removal.On 10/8/25 at 8:17 AM, Surveyor observed R11 in R11's bathroom wearing Tubigrips and waiting for assistance.
R11 indicated R11 slept in the Tubigrips. On 10/8/25 from 8:19 AM to 8:24 AM, Surveyor interviewed CNA-Q, CNA-R, CNA-S, and CNA-T (all assigned to R11's hallway) who denied applying R11's Tubigrips that morning and verified R11's Tubigrips should be applied in the morning and removed in the evening. On 10/8/25 at 12:49 PM, Surveyor interviewed DON-B who indicated staff should follow medical orders for Tubigrips.
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Samaritan Nursing and Rehab 531 E Washington St West Bend, WI 53095
indicated staff denied knowledge that R4 had vomited. On 10/8/25 at 10:51 AM, Surveyor interviewed
jeopardy to resident health or staff were interviewed and unaware that R4 had vomited.
When Surveyor asked if PM shift staff were safety interviewed, DON-B stated DON-B did not interview PM shift staff and did not have evidence that R4 vomited or had a change in condition. VPS-K stated R4 did not have a change in condition, so
were completed and showed no change in condition. ~ On the 8/27/25 into 8/29/25 NOC shift. On 10/7/25 at 12:37 PM, Surveyor interviewed Medical Examiner (ME)-E who completed R4's death investigation. ME-E stated after a discussion with R4's family and Hospice staff, a post-mortem CT scan was completed on 9/3/25 and showed no signs of bleeding. ME-E stated after review of R4's fall, Hospice notes, and R4's medical record, ME-E concluded R4's death was an accident due to the fall.
The Medical Examiner's report indicated R4's cause of death was a concussion in the setting of Parkinsonism. A Death Certificate Summary, completed by ME-E, listed R4's manner of death as an accident, with sub manner listed as fall.
The cause of death was listed as a concussion in the setting of Parkinsonism with other significant conditions contributing to the death, including right orbital floor blowout fracture and history of a CVA.
The failure to properly position a resident with left-sided hemiparesis and properly monitor and assess the resident following a fall created a reasonable likelihood for serious harm or injury, thus leading to a finding of immediate jeopardy.
The facility removed the immediate jeopardy on 10/12/25, however, the deficient practice continues at a scope/severity level D (potential for more than minimal harm/isolated) as the facility continues to implement the following action plan:1.
Reviewed, screened, and updated care plans for residents with diagnoses of hemiparesis and falls related to bed mobility. 2.
Met with Hospice staff to ensure effective communication in real time regarding changes in condition.
Updates should be given to the DON or designee before Hospice staff leave the building.3.
Educated facility and agency staff on bed mobility, post-fall assessments, and changes in condition prior to their next scheduled shift.4.
Initiated bed mobility and change in condition competencies for 4 weeks to ensure staff follow proper techniques and protocols. Ad hoc education to be provided immediately when indicated.
525165 10/16/2025
Samaritan Nursing and Rehab 531 E Washington St West Bend, WI 53095
respiratory care and services for 1 Resident (R) (R1) of 4 sampled residents.R1 received supplemental
10/8/25, Surveyor requested the facility's oxygen policy and procedure from Director of Nursing (DON)-B who provided an undated Oxygen Guideline Policy Interpretation and Implementation and Fire Prevention form that addressed oxygen safety and fire prevention. DON-B indicated the facility did not have another oxygen policy.
From 10/7/25 to 10/8/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including malignant neoplasm of the bladder, secondary neoplasm of the bone, toxic encephalopathy, and osteoporosis with current pathological fractures. R1's most recent Minimum Data Set (MDS) assessment, dated 9/25/25, had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R1 had moderate cognitive impairment. R1 had an activated Power of Attorney for Health Care (POAHC).On 10/7/25 at 9:45 AM, Surveyor interviewed R1 and observed an oxygen concentrator at R1's bedside.
When Surveyor asked if R1 needed oxygen, R1 indicated R1 didn't know. R1 did not appear short of breath (SOB) during the interview.R1's medical record did not contain an order for oxygen. In addition, R1's care plan did not address oxygen use.
Progress notes in R1's medical record indicated R1 required oxygen after a change in respiratory status on 9/13/25. On 10/7/25 at 10:50 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-G who was unsure if R1 used oxygen and indicated oxygen use was not on R1's CNA care plan.On 10/7/25 at 12:21 PM, Surveyor interviewed Registered Nurse (RN)-F who verified R1 had an oxygen concentrator in R1's room but did not have an order for oxygen or a care plan that addressed oxygen use. On 10/7/25 at 1:15 PM, Surveyor interviewed DON-B who verified R1 did not have an order or a care plan for oxygen use. DON-B located an oxygen order from R1's Hospice provider, dated 9/17/25, that indicated: Inhale 1-5 liters per minute (LPM) into the lungs continuous as needed (PRN) for dyspnea. DON-B indicated the order was entered into R'1s medical record during the survey on 10/7/25. On 10/8/25, Surveyor reviewed R1's medical record and noted an order, dated 9/13/25, that indicated: In emergency, apply oxygen at 2 liters/minute per nasal cannula every 4 hours as needed for standing order.
Obtain a set of vital signs.
Notify physician if continuous oxygen is needed.
Surveyor verified with DON-B that the order was entered on 10/7/25.
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Samaritan Nursing and Rehab 531 E Washington St West Bend, WI 53095
services of a licensed pharmacist.
staff interview and record review, the facility did not provide pharmaceutical services to ensure the
simple sugar related to glucose considered effective for treating carbohydrate-deficient glycoprotein syndrome and can help with digestive issues, low blood sugar and blood clotting disorders), nateglinide (an oral medication used to manage type 2 diabetes), and pregabalin (an anticonvulsant medication) were not administered to R2 in accordance with physician orders.
Findings include:The facility's Administering Medications policy, dated 5/2025, indicates: Medications shall be administered in a safe and timely manner and as prescribed .3.
Medications must be administered in accordance with the orders, including any required time frames. 4.
Medications must be administered within one hour of their prescribed time, unless otherwise specified .From 10/7/25 to 10/8/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including left total knee arthroplasty, osteoarthritis left knee, cellulitis left lower limb, and diabetes.
R2's Minimum Data Set (MDS) assessment, dated 9/24/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R2 had intact cognition. R2 was responsible for R2's healthcare decisions.R2's medical record indicated R2 had the following physician orders:~ D-Mannose oral capsule 500 milligrams (mg) give 1 capsule by mouth in the morning for supplement, dated 9/18/25.~ Nateglinide oral tablet 120 mg give 0.5 tablet by mouth three times daily for diabetes, dated 9/18/25.~ Nateglinide oral tablet 60 mg give 1 tablet by mouth three times daily for diabetes, dated 9/20/25.~ Pregabalin oral capsule 50 mg give 1 capsule by mouth three times daily for nerve pain, dated 9/18/25.Surveyor reviewed a Medication (Administration) Audit Report for R2 for 9/18/25 through 9/25/25 that indicated the following:~ On 9/19/25, R2's D-Mannose was not administered because the medication was unavailable.~ On 9/18/25, R2's 9:00 PM dose of nateglinide was not administered because the medication was unavailable.~ On 9/19/25, R2's 9:00 AM, 2:00 PM, and 9:00 PM doses of nateglinide were not administered because the medication was unavailable.~ On 9/20/25, R2's 9:00 AM dose of nateglinide was not administered because the medication was unavailable.~ On 9/20/25, R2's 12:00 PM and 5:00 PM doses of nateglinide were not administered because the medication was unavailable.~ On 9/21/25, R2's 12:00 PM dose of nateglinide was not administered because the medication was unavailable.~ On 9/18/25, R2's 8:00 PM dose of pregabalin was not administered because the medication was unavailable.~ On 9/19/25, R2's 8:00 AM, 2:00 PM, and 8:00 PM doses of pregabalin were not administered because the medication was unavailable.~ On 9/20/25, R2's 8:00 AM and 2:00 PM doses of pregabalin were not administered because the medication was unavailable.On 10/8/25 at 10:19 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated the pharmacy should deliver a medication when it is ordered. DON-B stated if the pharmacy does not deliver a medication, staff should call the pharmacy with a stat (immediate) order to obtain the medication timely.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.