Wibaux County Nursing Home

In the surveyor’s words

From the most serious findings on record at Wibaux County Nursing Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 24, 2025

  Based on interviews and record reviews, a facility staff member failed to transfer a resident properly while using a mechanical lift and ensure that two staff members were assisting. The resident fell from the lift and sustained a fracture, a head injury, and passed away at the hospital. Documentation reflected that the fall contributed to the resident's death, for 1 (#1) of 7 sampled residents. Findings include: On [DATE] at 11:35 a.m., the facility Administrator, Assistant Administrator/Business Office Manager, and the Director of Nursing were notified of an Immediate Jeopardy (IJ) situation, which involved resident #1 related to a fall with major injuries. The IJ pertained to F689 - Free of Accident Hazards/Supervision/Devices. […]

• Actual harm, isolatedF600Sep 24, 2025

  Based on interviews and record review, the facility staff failed to protect 1 (#1) of 8 residents sampled for neglect of care by the staff when safe lifting practices were not employed during resident transfers with a mechanical lift, and the facility policies were not followed. Findings include:During an interview on [DATE] at 2:01 p.m., NF1 said, “I had been a [position title] for seven years, and I never used mechanical lifts by myself before coming here. I knew I should have a second person to assist because I was trained and have always had two people for lifts. […]

• Actual harm, isolatedF686Feb 29, 2024

  Based on observation, interview, and record review, the facility failed to implement appropriate measures to prevent skin breakdown, to provide consistent care, monitoring, and treatment of pressure ulcers for 1 (#14) of 16 sampled residents, resulting in the development of one Unstageable pressure ulcer on the right ankle and one Stage Two pressure ulcer on the right buttock. The deficient practice had the potential to cause worsening of wounds and infection for the resident. Findings include: During an observation on 2/27/24 at 12:01 p.m., resident #14 was observed sitting in his Geri Chair (special wheelchair) with no pressure relieving cushion in place. During observations of resident #14's bed, on 2/27/24 at 2:40 p.m. […]

• No harm, potential for more than minimal, widespreadF880Apr 9, 2026

  Based on observation, interview, and record review, the facility failed to implement an effective infection prevention and control program, including failure to ensure Enhanced Barrier Precautions (EBP) were implemented for 2 (#s 1 and 4) of 13 sampled residents; and failed to implement a system for the ongoing surveillance, identification, and prevention of infections for all residents. The failures placed residents at risk for developing and transmitting infections. Findings include: Enhanced Barrier Precautions: 1. During an interview on 4/8/26 at 11:52 a.m., staff member J stated resident #1 had an open pressure wound on her left heel and coccyx area. […]

• No harm, potential for more than minimal, widespreadF882Apr 9, 2026

  Based on interview and record review, the facility failed to ensure the designated infection preventionist was qualified by education, training, or experience to oversee the infection prevention and control program for the facility. The failure placed all residents at increased risk for the development and transmission of infections. Findings include:During an interview on 4/8/26 at 1:33 p.m., staff member A stated staff member B started in her role at the facility on 11/4/25, and had been taking the CDC Infection Preventionist certification training, but was only up to module eight because she was busy filling in on the floor as needed and had not had time to complete the training. […]