Walworth County Care Center, Inc

Review of resident 1's electronic medical record (EMR) revealed he was hospitalized from [DATE] through 1/13/26 for treatment of a left femur (thigh bone) fracture. A 1/8/26 urology progress note indicated the resident's Foley catheter was removed, and he was able to urinate. A 1/10/26 Discharge Disposition note from the hospital stated that a Foley catheter was placed on 1/10/26.

The 1/13/26 Discharge to SNF (skilled nursing facility) form included an area for instructions regarding the removal of the Foley catheter, catheter care instructions, and the indication for the catheter, but that area was not completed. A 1/23/26 faxed communication from the provider's nursing staff to resident 1's physician asked about discontinuing the resident's Foley catheter.

The physician's response was Start Alfuzosin (a medication used to treat symptoms of enlarged prostate) 10 mg [milligrams] once daily for 4 days then attempt [a] trial without [the] catheter. On 1/30/26, the resident's physician was faxed a nursing communication indicating that a 1/29/26 trial removal of the resident's Foley catheter was not successful, and a catheter was re-inserted.

The physician's response was Restart Foley [catheter] and f/u [follow-up] with urology. Resident 1's February 2026, March 2026, and April 2026 physician's progress notes regarding his assessment of the resident's urinary retention indicated, Referral to urology for further evaluation and care. Resident 1's 1/21/26 catheter care plan indicated the resident had a Foley catheter and included catheter care instructions.

There was no mention of a plan for removing the Foley catheter. 3.

Interview on 4/29/26 at 1:00 p.m. with licensed practical nurse (LPN) H regarding resident 1's urology consultation revealed she knew the resident was expected to be seen by a urologist, but did had not yet occur and she was not sure why. 4.

Interview on 4/30/26 at 9:45 a.m. with director of nursing (DON)/wound nurse B and assistant director of nursing (ADON)/infection preventionist (IP) C regarding urology consultations revealed the resident's physician was expected to call a urologist to make that referral.

The urology office would then call the facility to confirm the appointment time. ADON)/IP C was assigned to round (a process where healthcare staff, such as nurses and physicians, regularly visit residents to assess their needs, ensure safety, and improve care quality) with resident 1's physician during his monthly resident visits.

The status of resident 1's urology consultation should have been discussed during those rounds. DON/wound nurse B and ADON/IP C revealed ADON/IP C recalled discussing the urology consultation with resident 1's physician during his January 2026 rounds. It was ADON/IP C's understanding that the physician would call the urologist to make the referral. ADON/IP C confirmed during the February 2026, March 2026, and April 2026 rounds that she did not discuss the status of resident 1's urology consultation with the physician. At no other time outside of the monthly rounds had she spoken with resident 1's physician about the urology consultation. DON/wound nurse B acknowledged the failure to follow the January 2026 physician-ordered urology consultation for resident 1 was 100% on us [the facility.] 5.

Review of the undated Registered Nurse (RN) job description revealed duties and responsibilities include Assist in developing methods for coordinating nursing services with other resident services to ensure the continuity of the residents' total regimen of care.

435123 04/30/2026

Walworth County Care Center, Inc 4861 Lincoln Avenue Selby, SD 57472

Review of the provider's undated Pressure Ulcers/Skin Breakdown Clinical Protocol policy revealed that the nurse was to document and report the pressure ulcer, but it did not indicate how often it should be done or who it was to be reported to.

The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings., and applications of topical agents.

The physician will help identify medical interventions related to wound management.

The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. 11.

Review of the provider's February 2021 Change in a Resident's Condition or Status policy revealed the nurse was to notify a resident's physician within twenty-four hours when a resident has a significant change of condition.

The policy defined significant change of condition as a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not ?self-limiting'),. and it requires interdisciplinary [a group of experts from different fields] review and/or revision to the care plan [personalized plan that addresses a resident's care needs, goals, and interventions].

435123 04/30/2026

Walworth County Care Center, Inc 4861 Lincoln Avenue Selby, SD 57472

Observation and interview on 4/29/26 at 9:00 a.m. with CNA/RMA G in resident 11's room revealed CNA/RMA G used a sit-to-stand lift (a mechanical lift used to assist from a seated to a standing position) to transfer resident 11 from her wheelchair to the toilet. CNA/RMA G referred to the Kardex (a report of the resident's care needs and interventions) to know that resident 11 was to be transferred using a mechanical lift. 3.

Review of resident 11's electronic medical record (EMR) revealed her Brief Interview for Mental Status assessment score was one, which indicated her cognition was severely impaired.

Her 3/19/26 Morse Fall assessment score was 30, which indicated had a moderate risk for falling. Resident 11's revised 3/31/26 care plan (a personalized plan that addresses a resident's care needs, goals, and interventions) related to her transfer needs indicated that resident 11 usually requires dependent staff assistance with sit-to-stand transfers and with chair/bed-to-chair transfers. [Resident 11] requires [a] Hoyer lift [a full body lifting device used to assist from a seated to a standing position] with staff assist x 2 [assistance by two staff persons] for transfers when she is not placing her feet on the ground for a pivot transfer with gait belt and staff assist x 1-2 [assistance by one to two staff persons] or in the sit-to-stand lift. 4.

Interview on 4/30/26 at 10:00 a.m. with director of nursing (DON)/wound nurse B regarding revealed that the therapy department assessed each resident's mobility and transfer needs.

Their recommendations were added to be added to the resident's care plan.

That care plan information was then transferred to the resident's Kardex so staff members knew how to care for the resident.DON/wound care nurse B acknowledged that resident 11 was improperly and unsafely transferred by CNA/RMA E and CNA F when they failed to follow the transfer recommendations identified in the resident's care plan and on the resident's Kardex.

That failure placed resident 11 at risk for falling and injuring herself.

She expected staff to follow care-planned interventions for the safe transfer of all residents.

Review of the provider's revised December 2024 Enhanced Barrier Precautions policy revealed, EBP are utilized to prevent the spread of multi-drug resistant organisms (MDROs) during high contact resident care activities. EBP were to be used when A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical device, and does not have secretions or excretions that cannot be covered or contained . and EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply.

Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include:. changing [resident's incontinence (involuntary urine or bowel leakage)] briefs or assisting [the residents] with toileting and transferring.

Review of the provider's revised September 2022 Cleaning and Disinfection of Resident-Care Items and Equipment policy revealed Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment).

Review of the provider's undated Proper Procedure to Clean a Room document revealed that the staff were to wash their hands after cleaning a bathroom, and before and after mopping a resident's room.

Review of the provider's undated Handwashing/Hand Hygiene policy revealed, This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.

Hand hygiene was to be performed after contact with items in a resident's room and after removing gloves.

435123 04/30/2026

Walworth County Care Center, Inc 4861 Lincoln Avenue Selby, SD 57472