Samaritan Nursing And Rehab
Inspection Findings
F-Tag F0684
F 0684 Level of Harm - Immediate jeopardy to resident health or safety
- 3. On 11/4/25, Surveyor reviewed Resident R4's medical record. Resident R4 was admitted to the facility on [DATE REDACTED] and had
diagnoses including sepsis, systemic sclerosis with lung involvement, Raynaud's disease (causes some areas of the body, such as fingers and toes, to feel numb and cold in response to cold temperatures), and pulmonary hypertension due to scleroderma. Resident R4's MDS assessment, dated 9/21/25, had a BIMS score of 15 out of 15 which indicated Resident R4 had intact cognition. Resident R4 was responsible for Resident R4's healthcare decisions.
Residents Affected - Few
Resident R4's medical record contained the following wound orders: ~ Bilateral lower extremity: Cleanse, apply Iodosorb, cover with methylene blue and ABD pad, secure with Kerlix, change daily every day shift for open area (dated 10/24/25) ~ Coccyx wound: Cleanse with soap and water, pat dry, skin prep peri wound, apply Medihoney, cover with bordered gauze every day shift for open area (dated 11/2/25).
On 11/4/25 at 10:52 AM, Surveyor observed Registered Nurse (RN)-E provide wound care to Resident R4's BLE and coccyx wounds. RN-E removed the lower extremity dressings and sprayed both wounds with lidocaine.
Surveyor observed a purple color in between Resident R4's toes. RN-E indicated the color was due to gentian violet which staff used every other day. RN-E then removed Resident R4's coccyx dressing, cleansed the wound with soap and water, and applied Iodosorb.
On 11/4/25 at 11:25 AM, Surveyor interviewed RN-E who indicated the facility was out of Medihoney which was on back order. RN-E indicated the MD was aware and allowed staff to use Iodosorb instead.
On 11/4/25 at 3:19 PM, Surveyor interviewed DON-B who verified Resident R4 did not have orders for lidocaine, gentian violet, or Iodosorb to replace Medihoney.
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
11/11/2025
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-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
completed for 3 days. On 10/20/25, Resident R5 fell when Resident R5 tried to grab an item off the ground from bed. Resident R5's call light was activated. The facility did not provide a fall report with the IDT review but provided a handwritten falls checklist. Handwritten on the front of the report was: Intervention: 30 minutes - 1 hour rounds for safety.
The checklist at #10 indicated: Add new focus update care plan Actual Fall Occurred. This was checked as completed. The checklist at #11 indicated: Add/update care plan with interventions under Risk for Falls. This was checked as completed.On 11/4/25 at 3:05 PM, Surveyor interviewed Resident R5 who indicated Resident R5 never had bolsters or a mat next to Resident R5's bed, however, staff put Resident R5's bed in a low position. Resident R5 indicated Resident R5 wouldn't want a bolster or mat next to the bed and would be afraid Resident R5 would trip. Resident R5 acknowledged that Resident R5 self-transfers when Resident R5 should wait for assistance.On 11/4/25, Surveyor noted none of the interventions from Resident R5's falls on 7/2/25, 7/7/25, or 7/23/25, or 10/20/25 were added to Resident R5's care plan.On 11/4/25 at 2:43 PM, Surveyor interviewed [NAME] President of Clinical Operations (VPCO)-D who indicated the facility's policy is to initiate immediate interventions. The IDT team then meets to review the fall. VPCO-D indicated sometimes the immediate interventions are changed and other interventions are added. VPCO-D confirmed
after a new intervention is determined, the resident's care plan should be updated. VPCO-D acknowledged that Resident R5's care plan was not updated.
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
11/11/2025
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)
SAMARITAN NURSING AND REHAB in WEST BEND, WI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in WEST BEND, WI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from SAMARITAN NURSING AND REHAB or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.