Samaritan Nursing and Rehab
531 E Washington St · West Bend, WI · 53095 · 2623354500
131 certified beds For profit - Corporation Chain: Shlomo Hoffman Part of a CCRC
Why this verdict
- Carries CMS’s abuse warning icon.
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (3 citations).
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $75,498 in fines in the last 24 months.
- Staffing hours comfortably above national benchmarks.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
3 immediate-jeopardy citations in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
2 abuse-related citations at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
$75,498 in federal fines in the last 24 months
1 fine — CMS fines are reserved for verified, serious non-compliance.
78% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 4 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 4.54 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 1.30 | 0.55–0.75 |
| Weekend hours / resident-day | 3.95 | ≈ weekday level |
| Nursing turnover / year | 78% | median 45% |
| Fines (3-yr window) | 1 · $75,498 |
Inspection citations (57 in the current record)
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Immediate jeopardy · J April 20, 2026 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected April 21, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D April 20, 2026 · found via complaint
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected April 21, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E April 20, 2026 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected April 21, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E April 20, 2026 · found via complaint
Respond appropriately to all alleged violations.
Corrected April 21, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D April 20, 2026 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected April 21, 2026 · Quality of Life and Care
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Potential for harm · D April 20, 2026 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected April 21, 2026 · Quality of Life and Care
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Potential for harm · D April 20, 2026 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected April 21, 2026 · Quality of Life and Care
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Potential for harm · D April 20, 2026 · found via complaint
Ensure medication error rates are not 5 percent or greater.
Corrected April 21, 2026 · Pharmacy Service
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Potential for harm · D April 20, 2026 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected April 21, 2026 · Pharmacy Service
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Potential for harm · D April 20, 2026 · found via complaint
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.
Corrected April 21, 2026 · Nutrition and Dietary
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Potential for harm · F April 20, 2026 · found via complaint
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected April 21, 2026 · Administration
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Potential for harm · D April 20, 2026 · found via complaint
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected April 21, 2026 · Nursing and Physician Services
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Potential for harm · D March 11, 2026 · found via complaint
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected March 12, 2026 · Nutrition and Dietary
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Immediate jeopardy · J November 11, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected December 17, 2025 · Quality of Life and Care
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Potential for harm · D November 11, 2025 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected December 17, 2025 · Quality of Life and Care
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Potential for harm · D November 11, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected November 12, 2025 · Quality of Life and Care
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Potential for harm · D November 11, 2025 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected December 17, 2025 · Pharmacy Service
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Immediate jeopardy · J October 16, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected October 17, 2025 · Quality of Life and Care
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Potential for harm · D October 16, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected October 17, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D October 16, 2025 · found via complaint
Respond appropriately to all alleged violations.
Corrected October 17, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D October 16, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected October 17, 2025 · Quality of Life and Care
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Potential for harm · D October 16, 2025 · found via complaint
Provide safe and appropriate respiratory care for a resident when needed.
Corrected October 17, 2025 · Quality of Life and Care
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Potential for harm · D October 16, 2025 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected October 17, 2025 · Pharmacy Service
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Potential for harm · E August 26, 2025 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected September 19, 2025 · Pharmacy Service
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Potential for harm · E August 26, 2025 · found via complaint
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected September 19, 2025 · Pharmacy Service
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| November 11, 2025 | Payment Denial | 8 days |
| October 16, 2024 | Fine | $75,498 |
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 525165 · certified since March 27, 1967. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.