Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at West Bend Health And Rehabilitation during CMS and state inspections, most recent first.
Missing employee background screening documentation was cited after file review and staff interviews showed incomplete SING and criminal background check records for a CNA and an LPN. One CNA’s SING showed a possible criminal hit that required DCI clarification, but the file lacked proof the follow-up was completed, and the LPN’s file had no SING or background check documentation. The Administrator stated the employee file system upgrade resulted in missing parts of personnel files, and she did not know this was an issue before the survey.
Failure to notify the LTC Ombudsman of a resident transfer occurred when a resident with cancer, HTN, DM, depression, and moderately impaired cognition was sent to the hospital and later readmitted. The resident’s name was missing from the ombudsman transfer notice and the admission/discharge report, and the SW stated she believed notification was only needed for discharge to the community.
A resident with moderate cognitive impairment was subjected to disrespectful treatment by a CNA who used profanity and derogatory language about her frequent call light use. This led the resident to feel like a burden and choose to wet herself rather than call for assistance. The incident was reported by multiple staff members who witnessed the behavior during walking rounds.
A facility failed to ensure proper medication administration for a resident with moderate cognitive impairment. An agency RN left medications in the resident's room, which were later administered by a CNA/CMA. The resident confirmed that medications were sometimes left for her to take at her convenience. The facility's policy requires licensed personnel to administer medications and document any deviations, but the resident had not been assessed for self-administration.
A facility failed to maintain personal hygiene for a resident dependent on staff for care, resulting in the resident being found saturated in urine multiple times. Staff interviews revealed inadequate checks for incontinence and a pattern of residents with dry briefs but wet bed pads and sheets. Conflicts between shifts and improper care practices were reported, with the facility's administrator acknowledging issues in changing wet linens.
Missing Employee Background Screening Documentation
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited after personnel file reviews, staff interviews, and facility policy review showed missing screening documentation for 2 of 5 current employees sampled. The facility reported a census of 43 residents. For Staff B, a CNA with a documented hire date of 10/8/2025, the Single Contact License and Background Check (SING) dated 10/6/25 showed a possible criminal hit that required the Department of Criminal Investigation (DCI) to clarify whether the prospective employee did or did not have a criminal history, but the personnel record did not contain documentation that the additional DCI research had been completed. For Staff C, an LPN with a documented hire date of 11/3/2025, the facility could not provide documentation of the SING or the background check, and the personnel record lacked that documentation. During interviews, the Administrator and Business Office Manager stated the SING system had a new upgrade and the employee file program also upgraded, resulting in missing parts of personnel files. The Administrator later stated she did not have the SING or background check to provide and did not know this was an issue prior to the survey. The facility policy stated prospective employees are to be screened prior to hire, including criminal background screening for CNAs and verification of licenses for all licensed employees.
Failure to Notify LTC Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the LTC Ombudsman for 1 of 2 residents reviewed who transferred to the hospital and later returned to the facility. Resident #5 had diagnoses of cancer, hypertension, diabetes mellitus, and depression, and the MDS documented a BIMS score of 11, indicating moderately impaired cognition. On 3/30/26 at 11:20 p.m., Resident #5 was transferred to the emergency department and admitted to the hospital, then readmitted to the facility on 4/2/26 at 12:20 p.m. The resident’s census tab listed the stay as hospital leave on 3/30/2026 and private on 4/2/2026, and the MDS listing showed discharge return anticipated on 3/30/26 and entry on 4/2/26. Review of the facility’s Notice of Transfer Form to Long Term Care Ombudsman, which was undated, did not include Resident #5’s name. The Admission/Discharge to/from report dated 3/1/26 to 4/30/26 also did not include Resident #5’s name, and this report was attached to the ombudsman notice form. Staff A, the Social Worker, stated she thought the notice was only required if residents were discharged to the community and verified Resident #5 was not on the list sent to the ombudsman. The Administrator stated the facility had identified an issue with its software and that Resident #5 was missed because of the way the resident was entered in the census tab.
Resident Dignity Compromised by Staff Behavior
Penalty
Summary
The facility failed to treat a resident with dignity and respect, as evidenced by an incident involving a Certified Nursing Assistant (CNA) who used profanity and derogatory language about the resident's frequent use of the call light. The resident, who had moderate cognitive impairment and a diagnosis of non-Alzheimer's dementia, was left feeling like a burden and chose to remain in bed and wet herself rather than call for assistance. This incident was reported by multiple staff members who witnessed the CNA's behavior during walking rounds. The resident's care plan identified her as being at risk for depression, with interventions to monitor and report signs of distress. Despite this, the resident was subjected to disrespectful treatment, which led to her feeling distressed and neglected. The facility's failure to address the resident's needs and ensure respectful communication contributed to the deficiency, as the resident's rights to dignity and respectful care were not upheld.
Failure to Follow Medication Administration Standards
Penalty
Summary
The facility failed to ensure that staff followed professional standards for administering medication to a resident with moderate cognitive impairment and non-Alzheimer's dementia. On a specific day, a Certified Nursing Assistant/Certified Medication Aide (CNA/CMA) discovered pills left on the resident's table, which were supposed to be administered that morning. The CNA/CMA confirmed with the nurse that these medications were left by an agency Registered Nurse (RN), who admitted to leaving the medications in the resident's room. The resident confirmed that medications were sometimes left in her room for her to take at her convenience. The facility's policy on medication administration requires that only licensed medical and nursing personnel prepare, administer, and record medication administration. Medications must be given according to the resident's service plan, and any deviations must be documented on the Medication Administration Record (MAR). However, the interim Director of Nursing (DON) stated that the resident had not been assessed for self-administration of medications, indicating a failure to adhere to the facility's policy and professional standards.
Failure to Maintain Personal Hygiene and Change Soiled Linens
Penalty
Summary
The facility failed to provide necessary services to maintain personal hygiene for a resident who was unable to do so independently. The resident, who had no cognitive impairment, was dependent on staff for activities of daily living due to conditions such as traumatic spinal cord dysfunction, diabetes, and hemiplegia. The care plan required two staff members to assist with toileting and repositioning, and the resident was to be checked regularly for incontinence. However, on multiple occasions, the resident was found saturated in urine, indicating that staff did not change her as required. Staff interviews revealed that the resident was not properly checked for incontinence, and there was a lack of communication and accountability among shifts regarding the resident's care. Additionally, there was a pattern of residents being found with dry briefs but wet bed pads and sheets, suggesting that staff were not adequately changing linens or checking for incontinence. Staff members reported conflicts between shifts and a lack of proper care, with some residents being put to bed in their day clothes. The facility's administrator acknowledged that wet linens should be changed but suggested that low lighting and gloves might prevent staff from noticing wetness. This indicates a systemic issue in the facility's care practices, leading to the deficiency in maintaining personal hygiene for residents.
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Illustrative
What surveyors actually found near you
We read the 32 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near West Bend
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan - Algona | 12.9 mi | ★★★★★ | 3 | 0 |
| Algona Manor Care Center | 14.3 mi | ★★★★★ | 2 | 0 |
| Emmetsburg Care Center | 15.5 mi | ★★★★★ | 10 | 0 |
| Lakeside Lutheran Home | 16.2 mi | ★★★★★ | 6 | 0 |
| Palo Alto County Hospital | 16.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.