Samaritan Nursing And Rehab

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

misappropriation was not reported to law enforcement or the SA. On 10/8/25 at 1:00 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated NHA-A did not believe Resident R1's missing iPad was an allegation of misappropriation since the iPad was not on Resident R1's inventory list and staff did not recall seeing the iPad. NHA-A indicated NHA-A did not believe Resident R1 had an iPad in the facility. 2. From 10/7/25 to 10/8/25, Surveyor reviewed Resident R17's medical record. Resident R17 had diagnoses including dementia and neurocognitive disorder with Lewy bodies. Resident R17's most recent MDS assessment, dated 8/4/25, had a BIMS score of 1 out of 15 which indicated Resident R17 had severe cognitive impairment. Resident R17 had an activated POAHC (POAHC-U).On 10/7/25, Surveyor reviewed a grievance filed on 9/24/25 by POAHC-U that indicated Resident 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 Resident R17 went to the hospital and returned with Resident R17's watch. After Resident R17 passed at the facility, POAHC-U went through Resident R17's belongings and indicated Resident 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 Resident 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 Resident R17's watch was missing. GO-I indicated Resident 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 Resident R17's watch was reported missing by POAHC-U two weeks after Resident 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.

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

10/16/2025

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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

passed away at the facility. POAHC-U indicated after going through Resident R17's personal belongings, POAHC-U noticed that Resident R17's watch was missing and reported the missing watch to Grievance Officer (GO)-I on 9/24/25. POAHC-U indicated the facility could not find Resident R17's watch and offered reimbursement. 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 a grievance was received on 9/24/25 that indicated Resident R17's watch was missing.

GO-I indicated Resident R17 passed away approximately 2 weeks prior to receiving 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 declined and was more concerned about the sentimental value.

GO-I verified the facility did 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 Resident R17's watch was reported missing by POAHC-U two weeks after Resident 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 Resident R17's missing watch.

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

10/16/2025

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 0684

evening. On 10/8/25 at 12:49 PM, Surveyor interviewed DON-B who indicated staff should follow medical orders for Tubigrips.

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

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

10/16/2025

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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

RNC-D were unsure why there was a line through the 8/28/25 PM shift neuro checks. RNC-D verified the checks should have been completed.On 10/7/25 at 3:33 PM, Surveyor interviewed POAHC-M via phone who stated Resident R4 threw up at least once per day after the fall until Resident R4 passed away on 8/30/25. POAHC-M stated staff did not report the vomiting episodes to POAHC-M, however, POAHC-M reported the episodes to staff if they occurred when POAHC-M was at the facility. POAHC-M stated a grievance form was completed and submitted to the facility; however, POAHC-M had not heard from the facility. POAHC-M stated Resident R4 vomited during POAHC-M's visit on 8/30/25. When POAHC-M attempted to assist Resident R4, POAHC-M realized Resident R4 was not breathing. POAHC-M yelled for Resident R4 to take a breath and called for help. A Concern/Comment Report submitted by Resident R4's family on 9/2/25 indicated on 8/27/25 at approximately 12:00 PM, Resident R4 threw up on Resident R4's clothes during a visit with family. Family requested that Resident R4 be changed. When other family members visited at 5:30 PM, Resident R4 was wearing the same clothes. The investigation summary stated DON-B reviewed the 8/27/25 schedule and interviewed all staff who worked the AM shift. DON-B indicated staff denied knowledge that Resident R4 had vomited. On 10/8/25 at 10:51 AM, Surveyor interviewed DON-B, VPS-K and RNC-D. DON-B verified DON-B investigated the grievance and indicated all AM shift staff were interviewed and unaware that Resident R4 had vomited. When Surveyor asked if PM shift staff were interviewed, DON-B stated DON-B did not interview PM shift staff and did not have evidence that Resident R4 vomited or had a change in condition. VPS-K stated Resident R4 did not have a change in condition, so physician notification was not necessary. RNC-D stated neurological checks and a BIMS assessment 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 Resident R4's death investigation. ME-E stated after

a discussion with Resident 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 Resident R4's fall, Hospice notes, and Resident R4's medical record, ME-E concluded Resident R4's death was an accident due to the fall. The Medical Examiner's report indicated Resident R4's cause of death was a concussion in the setting of Parkinsonism. A Death Certificate Summary, completed by ME-E, listed Resident 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.

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

10/16/2025

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 0695

Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, staff and resident interview, and record review, the facility did not provide the necessary respiratory care and services for 1 Resident (R) (Resident R1) of 4 sampled residents.Resident R1 received supplemental oxygen. Resident R1 did not have an order for oxygen or a care plan for oxygen therapy. Findings include:On 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 Resident R1's medical record. Resident R1 was admitted to the facility on [DATE REDACTED] and had diagnoses including malignant neoplasm of the bladder, secondary neoplasm of

the bone, toxic encephalopathy, and osteoporosis with current pathological fractures. Resident 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 Resident R1 had moderate cognitive impairment. Resident R1 had an activated Power of Attorney for Health Care (POAHC).On 10/7/25 at 9:45 AM, Surveyor interviewed Resident R1 and observed an oxygen concentrator at Resident R1's bedside. When Surveyor asked if Resident R1 needed oxygen, Resident R1 indicated Resident R1 didn't know. Resident R1 did not appear short of breath (SOB) during the interview.Resident R1's medical record did not contain an order for oxygen. In addition, Resident R1's care plan did not address oxygen use. Progress notes in Resident R1's medical

record indicated Resident 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 Resident R1 used oxygen and indicated oxygen use was not on Resident R1's CNA care plan.On 10/7/25 at 12:21 PM, Surveyor interviewed Registered Nurse (RN)-F who verified Resident R1 had an oxygen concentrator in Resident 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 Resident R1 did not have an order or a care plan for oxygen use. DON-B located an oxygen order from Resident 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 Resident 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.

Residents Affected - Few

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

10/16/2025

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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of medication for 1 Resident (R) (Resident R2) of 4 sampled residents.D-Mannose (a 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 Resident 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 Resident R2's medical record. Resident R2 was admitted to the facility on [DATE REDACTED] and had diagnoses including left total knee arthroplasty, osteoarthritis left knee, cellulitis left lower limb, and diabetes. Resident 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 Resident R2 had intact cognition. Resident R2 was responsible for Resident R2's healthcare decisions.Resident R2's medical record indicated Resident 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 Resident R2 for 9/18/25 through 9/25/25 that indicated the following:~ On 9/19/25, Resident R2's D-Mannose was not administered because the medication was unavailable.~ On 9/18/25, Resident R2's 9:00 PM dose of nateglinide was not administered because the medication was unavailable.~ On 9/19/25, Resident 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, Resident R2's 9:00 AM dose of nateglinide was not administered because the medication was unavailable.~ On 9/20/25, Resident R2's 12:00 PM and 5:00 PM doses of nateglinide were not administered because the medication was unavailable.~ On 9/21/25, Resident R2's 12:00 PM dose of nateglinide was not administered because the medication was unavailable.~ On 9/18/25, Resident R2's 8:00 PM dose of pregabalin was not administered because the medication was unavailable.~ On 9/19/25, Resident 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, Resident 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.

Event ID:

Facility ID:

If continuation sheet