Samaritan Nursing And Rehab
Samaritan Nursing and Rehab in West Bend, WI — inspection on November 11, 2025.
Found 2 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
jeopardy to resident health or safety
- On 11/4/25, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] 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. R4's MDS assessment, dated 9/21/25, had a BIMS score of 15 out of 15 which indicated R4 had intact cognition. R4 was responsible for R4's healthcare decisions.
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 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 R4's toes. RN-E indicated the color was due to gentian violet which staff used every other day. RN-E then removed 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 R4 did not have orders for lidocaine, gentian violet, or Iodosorb to replace Medihoney.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/11/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Samaritan Nursing and Rehab
531 E Washington St West Bend, WI 53095
SUMMARY STATEMENT OF DEFICIENCIES
completed for 3 days. On 10/20/25, R5 fell when R5 tried to grab an item off the ground from bed. 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 R5 who indicated R5 never had bolsters or a mat next to R5's bed, however, staff put R5's bed in a low position. R5 indicated R5 wouldn't want a bolster or mat next to the bed and would be afraid R5 would trip. R5 acknowledged that R5 self-transfers when R5 should wait for assistance.On 11/4/25, Surveyor noted none of the interventions from R5's falls on 7/2/25, 7/7/25, or 7/23/25, or 10/20/25 were added to 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 R5's care plan was not updated.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/11/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Samaritan Nursing and Rehab
531 E Washington St West Bend, WI 53095
SUMMARY STATEMENT OF DEFICIENCIES