
Report
TheVardellReport
Samaritan Nursing and Rehab
Skilled nursing facility and nursing facility
531 E Washington St
West Bend, WI 53095

TheVardellReport
Skilled nursing facility and nursing facility
531 E Washington St
West Bend, WI 53095
Life by Vardell Presents
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Across 13 inspections from November 2023 to August 2026, state surveyors documented 67 findings at Samaritan Nursing and Rehab; 67 have a recorded correction; CMS lists 4 enforcement actions in the window.
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2023 | 1 | 6 | 0 |
| 2024 | 2 | 3 | 1 |
| 2025 | 6 | 29 | 2 |
| 2026 | 4 | 29 | 1 |
Chronology
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
14 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
12 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
4 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
6 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
3 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
3 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
11 findings
The same visit included a complaint investigation.
Enforcement Action
Civil money penalty, $134,800 imposed October 16, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of January 29, 2025, the nearest before the penalty date.
Enforcement Action
Civil money penalty, $26,685 imposed November 11, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of January 29, 2025, the nearest before the penalty date.
Enforcement Action
Denial of payment imposed November 11, 2025. Status: Closed, December 17, 2025. CMS does not tie a penalty to a survey; listed with the standard health inspection of January 29, 2025, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
6 findings
The same visit included a complaint investigation.
Enforcement Action
Civil money penalty, $75,498 imposed October 16, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of November 2, 2023, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
Inspectors cited F755 in December 2024, January 2025, April 2025, August 2025, October 2025 and May 2026. This citation covers pharmacy services and the licensed pharmacist who oversees them. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F610 in November 2023, October 2025, April 2026 and August 2026. This citation covers how the home responds to and investigates an allegation of abuse, neglect or mistreatment. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F684 in November 2023, October 2025, November 2025 and April 2026. This citation covers whether residents receive the treatment their orders, preferences and goals call for. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F686 in November 2023, January 2025, July 2025 and November 2025. This citation covers how the home prevents and treats pressure injuries (bedsores). None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F689 in October 2025, November 2025, April 2026 and May 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F609 in October 2025, April 2026 and August 2026. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F803 in December 2024, January 2025 and April 2026. The agency describes it this way: Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F804 in August 2025, March 2026 and May 2026. This citation covers whether food and drink are palatable, attractive and served at a safe temperature. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F812 in November 2023, January 2025 and May 2026. This citation covers how food is stored, prepared and served. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F880 in November 2023, July 2025 and May 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F600 in October 2024 and April 2026. This citation covers whether residents are protected from abuse and neglect by anyone. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F607 in April 2026 and May 2026. The agency describes it this way: Develop and implement policies and procedures to prevent abuse, neglect, and theft. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F690 in January 2025 and May 2026. This citation covers continence care, catheter care and preventing urinary tract infections. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F760 in November 2025 and April 2026. This citation covers whether residents are free from significant medication errors. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F761 in August 2025 and May 2026. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
For Your Next Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
How often does the consultant pharmacist review each resident’s medications?
Pharmacy Services: cited in six inspections, most seriously at level E.
When an allegation is made, who investigates it, and how are residents protected in the meantime?
Investigating Alleged Violations: cited in four inspections, most seriously at level E.
How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?
Quality of Care: cited in four inspections, most seriously at level J.
How often are residents checked for pressure injuries and repositioned, and who is responsible for it?
Pressure Injury Care: cited in four inspections, most seriously at level E.
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in four inspections, most seriously at level J.
How are staff trained to report suspected abuse or neglect, and who reports it to the state?
Reporting Suspected Abuse: cited in three inspections, most seriously at level E.
What changed after F803 was cited, and how do you check it now?
Citation F803: cited in three inspections, most seriously at level E.
May we try a meal, and how do you check food temperature by the time it reaches residents?
Food Quality and Temperature: cited in three inspections, most seriously at level E.
May we see the kitchen, and what do your own sanitation checks look like week to week?
Kitchen and Food Safety: cited in three inspections, most seriously at level F.
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in three inspections, most seriously at level F.
What happened after the abuse or neglect citation, and what changed in training or supervision?
Protection From Abuse and Neglect: cited in two inspections, most seriously at level J.
What changed after F607 was cited, and how do you check it now?
Citation F607: cited in two inspections, most seriously at level D.
How is continence care scheduled, and how do you prevent urinary infections?
Continence and Catheter Care: cited in two inspections, most seriously at level D.
What happened after the medication error citation, and how are high-risk drugs double-checked?
Significant Medication Errors: cited in two inspections, most seriously at level D.
How are medications stored and secured, and who checks the medication carts?
Medication Labeling and Storage: cited in two inspections, most seriously at level E.
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
What led to the 2025 fine, and has it been paid?
A $26,685 civil money penalty was imposed November 11, 2025. CMS publishes the fine, not whether it has been paid. The record holds four enforcement actions in the window.
The Evidence
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Wisconsin state survey agency.
Wisconsin state survey agency
Inspection Nov 2, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Wisconsin state survey agency
Inspection Oct 16, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Wisconsin state survey agency
Inspection Dec 5, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Wisconsin state survey agency
Inspection Jan 29, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Wisconsin state survey agency
Inspection Apr 23, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Wisconsin state survey agency
Inspection Jul 29, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Wisconsin state survey agency
Inspection Aug 26, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Wisconsin state survey agency
Inspection Oct 16, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Wisconsin state survey agency
Inspection Nov 11, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Wisconsin state survey agency
Inspection Mar 11, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Wisconsin state survey agency
Inspection Apr 20, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Wisconsin state survey agency
Inspection May 18, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Wisconsin state survey agency
Inspection Aug 18, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Centers for Medicare & Medicaid Services · 525165
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Record windowNovember 2, 2023 – October 1, 2026
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.