Walworth County Care Center, Inc

In the surveyor’s words

From the most serious findings on record at Walworth County Care Center, Inc, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF880Apr 30, 2026

  Based on observation, interview, record review, and policy review, the provider failed to ensure the staff followed infection prevention and control practices by:One of one certified nurse aide (CNA)/registered medication aide (RMA) (N) and one of one RMA (O) who did not wear gowns, gloves, or perform hand hygiene (handwashing or sanitizing hands) while providing care for one of one sampled resident (1) on enhanced barrier precautions (EBP) (glove and gown use when providing contact care).One of one observed CNA/RMA (N) who did not clean an EZ stand lift (a mechanical lift used to assist from a seated to a standing position) after it was used to provide care for one of one sampled resident (1) on EBP. […]

• No harm, potential for more than minimal, isolatedF604Apr 30, 2026

  Based on observation, interview, record review, and policy review, the provider failed to ensure there was documentation to support if one of one sampled resident (3) was a candidate for a restraint (a device, material, or medication used to restrict a resident's movement or access to their body to ensure safety or prevent harmful behavior) reduction, a less restrictive restraint method, or for a restraint elimination.Findings include: 1.Observation on 4/29/26 at 8:00 a.m. in the dining room revealed resident 3 was seated in his wheelchair. The staff provided him with verbal and physical assistance to eat his breakfast. He repetitively moved his feet and gently rocked his trunk forward and back. Resident 3 moved his hand in and out of the waistband of his sweatpants several times. 2. […]

• No harm, potential for more than minimal, isolatedF658Apr 30, 2026

  Based on observation, record review, interview, and job description review, the provider failed to adhere to nursing professional standards of practice for following a physician's order for one of one sampled resident (1) with physician's orders for a urology consultation for evaluation and care. Findings include:1.Observation on 4/28/26 at 2:20 p.m. in resident 1's room revealed he was transferred from his wheelchair to his recliner by certified nurse aide (CNA)/registered medication aide (RMA) N and CNA/RMA O. The resident's Foley catheter (an indwelling tube inserted into the bladder to drain urine) urine collection bag was stored inside a cloth bag for dignity. 2. […]

• No harm, potential for more than minimal, isolatedF686Apr 30, 2026

  Based on observation, interview, record review, and policy review, the provider failed to assess, document, and notify the resident's physician of two facility-acquired pressure ulcers (skin and/or underlying tissue injury from prolonged pressure) for one of one sampled resident (12) who developed a pressure ulcer on her right heel and left buttock, and to complete wound assessment documentation weekly for her right inner buttock pressure ulcer by one of one director of nursing (DON)/wound nurse B and for nursing staff to monitor her right and left inner buttocks daily. Findings include:1. Observation and interview on 4/28/26 at 2:39 p.m. […]

• No harm, potential for more than minimal, isolatedF689Apr 30, 2026

  Based on observation, interview, record review, and policy review, the provider failed to ensure the safety of one of one sampled resident (11) who was observed not being transferred according to the resident's identified transfer assistance needs by one of one certified nurse aide (CNA) F and one of one CNA/registered medication aide (RMA) E which put the resident at risk for falling and sustaining an injury.Findings include:1.Observation on 4/28/26 at 5:20 p.m. in the dining room revealed resident 11 was heard calling out to the staff, Come here, come here. She had finished eating her evening meal. CNA F and CNA/RMA E approached the resident. […]