Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wibaux County Nursing Home during CMS and state inspections, most recent first.
Failure to implement infection prevention and control program: Two residents with wounds were not placed on EBP, and staff did not know when to use gowns and gloves for high-contact care or wound care. One resident had pressure ulcers on the heel and coccyx, and another had bilateral foot dressings with heel protectors. The IP staff member stated infections and pathogens were not being tracked or mapped, a recent Norovirus outbreak was not entered into the infection control logbook, and the logbook contained only nonspecific infection entries without surveillance or analysis.
Unqualified Infection Preventionist: The facility failed to ensure the designated infection preventionist was qualified by education, training, or experience to oversee the infection prevention and control program. An infection preventionist had started in the role and was responsible for the program, but stated she was still learning and had not finished the CDC infection preventionist course. A facility document identified the infection preventionist as the leader in surveillance activities and the person responsible for maintaining documentation of incidents, findings, and corrective actions.
The facility failed to timely report several allegations of abuse and neglect to the administrator and State Survey Agency as required by its policy. In one case, a resident experienced inadequate hygiene care and lack of monitoring after vomiting, identified later on video, but the allegation was not promptly reported. In another incident, a staff member’s physical contact caused a resident to lose balance and be assisted to the floor, and both the involved staff and a witness delayed notifying the nurse. In a third situation, a staff member allegedly verbally abused two residents by threatening a cold shower and ordering a resident to sit down and be quiet, and the witnessing staff member did not report these events until days later, resulting in late external reporting.
A resident with a history of aggressive behaviors experienced repeated episodes of emesis while seated in a recliner and remained in vomit-soiled conditions for an extended period. Camera review showed that, despite periodic checks and signs of restlessness and coughing, staff did not provide timely hygiene care, did not perform or document a physical assessment, and did not increase monitoring, aside from placing a towel and changing the resident’s shirt shortly before shift change. Nursing notes lacked documentation of assessment or interventions related to the emesis episodes, and the resident continued to exhibit verbal and physical aggression during later care attempts.
A resident's baseline care plan was not developed with the minimum necessary instructions for care. Nursing staff said they were responsible for starting the plan on admission, but the facility's software limited what could be included. The resident was admitted with multiple ongoing meds, including insulin, levothyroxine, lithium, olanzapine, pioglitazone, and rosuvastatin, yet the baseline care plan did not include a problem, goals, or interventions for med management.
A resident’s care plan was not revised to reflect current care needs. The resident was observed with heel protectors, and staff stated the resident had a pressure wound on the L heel. Record review showed an unstageable pressure ulcer on the L heel and a Stage II pressure ulcer on the coccyx, but the current care plan did not include these wounds or the use of heel protectors.
Inadequate Documentation of Wound Care and Dressing Status: A resident with wounds to the ankle, heel, and foot had orders for dressing changes every 3 days and monitoring every shift, but nursing documentation was sparse. Staff stated wound care was charted on the MAR and that progress notes should reflect wound dressing status every shift and at the time of dressing changes, yet the record showed only one comprehensive wound assessment and two additional wound-related entries over a 7-day period, despite multiple opportunities to document.
Failure to Monitor Antibiotic Use: The facility did not implement an effective antibiotic stewardship program or meaningfully track antibiotic use. The IP stated she was responsible for oversight but was not currently tracking pathogens or antibiotic data, and the Infection Control Log Book only listed non-specific infections such as UTI unspecified and respiratory infection unspecified without pathogen or C&S information. The facility policy called for documentation, data collection, meeting minutes, feedback reports, education records, and annual reports.
A resident with Anxiety, Depression, Schizoaffective Disorder, and Cerebral Palsy had PASRR Level I and Level II screenings on file, but the MDS section A was coded incorrectly on multiple comprehensive assessments. Staff stated PASRR information was overlooked because the system pre-populated demographic data, resulting in the resident being documented as not having SMI and/or ID/DD under the State PASRR process.
A staff member transferred a resident alone using a mechanical lift, contrary to the care plan requiring two staff, resulting in the resident falling and sustaining fatal injuries. Staff interviews revealed that single-person transfers with mechanical lifts were a common practice, and that staff had not received proper training or orientation on lift use. The incident was cited as an Immediate Jeopardy deficiency for failure to prevent accident hazards.
A resident who was fully dependent on staff for transfers was moved using a mechanical lift by only one staff member, contrary to the care plan and standard safe lifting practices. This occurred after the facility reduced staffing levels, leading to a fall that caused severe injuries, including a subdural hematoma and cervical fracture. The resident died three days later as a result of these injuries.
The facility did not ensure that nurses and CNAs received proper training or competency evaluation on mechanical lift procedures, with only one staff member having documented training. Staff reported a lack of formal instruction and were advised by peers to perform lift transfers independently. This deficiency was identified after a resident fell from a mechanical lift and sustained major injuries.
A resident who required total assistance for transfers was injured after falling from a Hoyer lift operated by a single CNA, despite the care plan requiring two staff. Staff interviews revealed that single-person mechanical lift transfers were a common and known practice due to reduced staffing levels, with management aware that policy was not being followed.
A resident who required total assistance for transfers was moved using a mechanical lift by only one staff member, contrary to the care plan and professional standards. Multiple staff confirmed they were trained to use two people for such transfers but sometimes worked alone due to staffing shortages, resulting in single-person use of the lift.
The facility did not ensure that the dietary manager had completed the required certification or higher education for the position. During observations and staff interviews, it was confirmed that the dietary manager was only partway through an online certification program and had not yet met the qualifications, an issue that had persisted since the last survey.
Two residents with cognitive impairment experienced multiple elopement incidents due to the facility's failure to timely identify risks, implement effective interventions, and ensure staff awareness. Window security was inadequate, elopement assessments were delayed, and staff did not consistently follow care plan interventions or recognize elopement events, resulting in ongoing hazards and insufficient supervision.
Surveyors found that several residents had incomplete or altered medical records, including missing signatures and dates on POLST forms, delayed completion of elopement assessments, and care plans containing irrelevant personal information about staff. Staff interviews confirmed that some documentation was intentionally altered or delayed, and facility policies on proper documentation were not consistently followed.
A resident with multiple mental health diagnoses and recent changes in psychotropic medications due to behavioral symptoms was not referred for a required Level II PASRR review. The staff member responsible did not complete the necessary Level I screening in a timely manner, and a completed Level I was not available during the survey.
The facility did not consistently develop and implement baseline care plans within 48 hours of admission for several residents. Staff interviews and record reviews showed that immediate care needs, such as fall risk, elopement risk, and psychotropic medication monitoring, were not promptly addressed in the care plans, leading to gaps in care planning for new admissions.
Two residents did not have individualized, comprehensive care plans addressing their specific needs. One resident's care plan lacked interventions for elopement risk and did not note their placement on a secure unit. Another resident's care plan failed to address her frequent crying, did not specify her activity preferences, and omitted guidance for staff regarding family attempts to remove her against medical advice.
Two residents did not receive individualized or meaningful activities, with one resident repeatedly pacing and attempting to exit the secured unit without staff engagement, and another resident left unengaged during a group activity. Staff did not follow care plan interventions or incorporate resident preferences into activity planning, and CNAs were often solely responsible for both monitoring and activities, leading to insufficient attention to residents' interests.
Two residents with severe cognitive impairment and on psychotropic medications were provided with bed grab bars without thorough assessment or documentation of risks and benefits. Staff did not attempt alternative interventions, failed to consider entrapment hazards, and did not document the impact of medications or resident conditions on safety. Required safety reviews and maintenance checks were also not completed.
A resident with severe cognitive impairment eloped from the facility and was absent for 12 hours, during which they stayed in a stranger's cabin overnight. The facility failed to inform the resident's family and provider about these details, preventing necessary medical evaluations. Staff acknowledged the expectation to report such events to the provider and family.
A resident with severe cognitive impairment eloped from the facility and spent the night at a stranger's cabin. Upon return, the facility failed to conduct a comprehensive physical or sexual assault assessment, contrary to their post-elopement procedures. Staff were unaware of the full details of the incident and did not follow the policy to ensure the resident's safety.
A cognitively impaired resident with a history of elopement attempts left the facility unsupervised overnight due to broken door alarms and inadequate monitoring. The resident exited through a memory unit door and a gate, both of which failed to alarm. Staff were aware of the broken alarms but did not implement effective measures to prevent the elopement. The resident was later found at an RV park across the road.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, including failure to ensure Enhanced Barrier Precautions (EBP) were used for two residents with wounds and failure to maintain an ongoing system for infection surveillance, identification, and prevention. Resident #1 had an open pressure wound on the left heel and a coccyx pressure ulcer, with physician orders dated 4/1/26 for dressing changes to the right heel and coccyx area. Staff members interviewed stated they were not aware EBP should be used for this resident, and one staff member stated she had not been wearing a gown when changing wound dressings. Resident #4 was observed in his room wearing heel protector boots over bilateral foot dressings, and he stated he was unaware he was on EBP and that staff only wore gloves when changing his foot dressings or assisting with personal care. Multiple staff members stated there were no residents on EBP, did not know when EBP should be used, or could not differentiate between infection control precautions. One staff member stated gowns and gloves were only used when emptying a catheter bag and not for personal care, and another stated staff had not been wearing gowns during wound care. No documentation of staff education on EBP was provided during the survey. The infection prevention and control program was also not being tracked effectively. The staff member responsible for infection prevention stated she had started in November 2025, was still learning, and had not finished the infection preventionist course. She stated infections and pathogens were not being tracked or mapped, and that a significant Norovirus outbreak in February 2026 had been reported to the health department but was not added to the infection control logbook. Review of the infection control logbook showed only nonspecific diagnoses such as UTI unspecified, history of UTI, and respiratory infection unspecified, with no infection surveillance or analysis, and the February 2026 infection summary showed no gastrointestinal infections. The facility’s infection surveillance policy stated that surveillance is a core activity of the infection prevention and control program to identify infections and monitor adherence to infection prevention and control practices.
Unqualified Infection Preventionist
Penalty
Summary
The facility failed to ensure the designated infection preventionist was qualified by education, training, or experience to oversee the infection prevention and control program. Staff member B started in the role in November 2025 and was responsible for the facility's infection prevention and control program, but stated she was still learning and had not finished the CDC Infection Preventionist course. Staff member A stated that staff member B had been taking the CDC training but had only completed module eight because she had been busy filling in on the floor as needed and had not had time to finish the course. A facility document titled Infection Surveillance, revised February 2026, identified the infection preventionist as the leader in surveillance activities and the person responsible for maintaining documentation of incidents, findings, and corrective actions.
Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
The deficiency involves the facility’s failure to timely report multiple allegations of abuse and neglect to the State Survey Agency and to the administrator as required by its Abuse, Neglect, and Exploitation policy. For one resident, an event involving lack of hygiene care and lack of monitoring after episodes of vomiting occurred during a night shift and was identified the following morning through review of video surveillance. Although the facility recognized the concern on that date, the allegation was not reported to the State Survey Agency until several days later, and staff acknowledged they did not realize it should have been reported at the time. In a separate incident, a staff member providing care to a resident made physical contact with the resident’s shoulder, causing the resident to lose balance and be assisted to the ground; the staff member did not report this event to the nurse because she did not believe it was reportable. Another staff member who witnessed the event also delayed reporting it to the nurse until the following day. In an additional event, a staff member allegedly verbally abused two residents by making a remark about giving one resident a cold shower to “cool” them off and telling another resident to sit down and be quiet. The witnessing staff member did not report these verbal abuse allegations to the nurse until two days later. These delays in internal reporting resulted in the facility failing to notify the State Survey Agency within the required 2-hour or 24-hour timeframes outlined in its written procedures.
Failure to Provide Hygiene Care and Assessment After Repeated Emesis
Penalty
Summary
The facility failed to provide necessary care and services to maintain a resident's quality of life, personal dignity, comfort, and safety when a resident experienced multiple episodes of vomiting while seated in a recliner. Camera footage documentation showed the resident vomited at 6:45 p.m. and 7:51 p.m., with no hygiene care provided following these episodes. The resident remained in vomit-soiled conditions, and although staff periodically checked on her throughout the early evening, she was noted to be restless and coughing until 8:48 p.m., with no further check by NF8 until 10:51 p.m. The only interventions documented were the placement of a towel and a shirt change shortly before shift change, and there was no evidence of a physical assessment, monitoring, or other interventions in response to the vomiting episodes. The resident had a documented history of aggressive behaviors and language in nursing progress notes from 2/1/26 to 3/31/26, which at times made it difficult for staff to provide care. On 4/8/26 at 7:35 a.m., the resident was observed with no skin breakdown, kept her eyes closed, and was verbally and physically aggressive to staff during repositioning for skin observation. Nursing progress notes dated 3/18/26 at 2:30 a.m. showed no documentation of physical assessment or increased monitoring following the vomiting episodes. Staff member A reported that NF8 and NF9, who were travel staff, had been assigned to the resident on the night shift when the vomiting occurred, and that video surveillance was reviewed after concerns were identified and reported the following morning.
Baseline Care Plan Missing Medication Management Details
Penalty
Summary
The facility failed to develop and implement a baseline care plan that included the minimum necessary instructions needed to provide effective and person-centered care for one resident. During an interview, staff member B stated nursing was responsible for starting baseline care plans on admission and that the plan should include the health information necessary to care for a resident properly. Staff member B also stated the facility used a software program to develop baseline care plans, but staff were not able to include all information related to a resident's care because of limitations with the program. Review of the resident's physician progress note showed the resident was to be admitted and continue multiple medications, including Lantus insulin, levothyroxine, lithium, melatonin, olanzapine, pioglitazone, and rosuvastatin. Review of the resident's baseline care plan, dated the day after admission, did not include a problem, goals, or interventions for medication management. The facility policy stated the baseline care plan was to be developed within 48 hours of admission and include the minimum healthcare information necessary to properly care for a resident, including physician orders.
Care Plan Not Updated for Pressure Wounds
Penalty
Summary
The facility failed to revise a resident's care plan to reflect current care needs for 1 of 13 sampled residents. During observation, the resident was sitting in a wheelchair at the dining table and had heel protectors on both feet. Staff later stated the resident had a pressure wound on the left heel and was unsure why the care plan had not been updated for it. Review of the physician progress note showed the resident had an unstageable pressure ulcer on the left heel and a Stage II pressure ulcer on the coccyx. Review of the current care plan showed it did not reflect the pressure wounds on the left heel and coccyx or the use of heel protectors.
Inadequate Documentation of Wound Care and Dressing Status
Penalty
Summary
The facility failed to ensure nursing staff documented wound care, wound status, and dressing changes in accordance with professional standards of practice for resident #4, who had wounds to the right ankle, right heel, and top of the foot. During observation, the resident was seen in his room with heel protector boots in place over bilateral foot wound dressings. Physician orders dated 3/31/26 directed that the right ankle wound, stage 2 pressure injury to the right heel, and top of foot wound each have dressing changes every 3 days, be monitored every shift, and have dressings changed as needed if saturated. During interviews, staff member H stated he only documented wound treatments or dressing changes if the wound looked a lot better or a lot worse. Staff member C stated she or staff member B completed weekly wound assessments, including measurements, evaluation, deterioration or healing, and physician notifications if needed, and that nursing staff were responsible for monitoring wound dressings and completing dressing changes per order. She also stated wound care was documented on the MAR, but nursing staff were expected to document wound dressing and status in the resident's medical record progress notes every shift and at the time of dressing changes. Review of the progress notes from 4/1/26 to 4/8/26 showed one comprehensive wound assessment on 4/2/26 and two additional wound-related entries, despite 14 opportunities to document wound status or dressing observations over seven days.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, including monitoring of antibiotic use within the facility. During an interview, staff member B stated she started in November 2025 and was responsible for the infection prevention and control program, including oversight of antibiotic use. She stated providers were good about obtaining cultures and changing or discontinuing antibiotics based on culture and sensitivity reports, but she was not currently tracking the information. She also stated, "I am just learning. It makes perfect sense to track the pathogens and antibiotics, and I will start tracking and monitoring them now." Review of the facility's Infection Control Log Book showed monthly reports generated from the electronic health record system of antibiotics in use, but the infections listed were non-specific entries such as UTI unspecified, history of UTI, and respiratory infection unspecified. The logbook contained no identified pathogen or culture and sensitivity information for prescribed antibiotics, and antibiotic use was not being meaningfully tracked or analyzed to support appropriate prescribing. Review of the Antibiotic Stewardship Program policy, revised February 2026, showed that documentation related to the program was to be maintained by the Infection Preventionist, including data collection forms for antibiotic use, process, and outcome measures, antibiotic stewardship meeting minutes, feedback reports, records related to education, and annual reports.
Incorrect PASRR Coding on MDS Assessments
Penalty
Summary
The facility failed to accurately complete multiple comprehensive MDS assessments for one resident’s PASRR information. During interview, staff stated the resident’s PASRR Level One was completed and a PASRR Level Two was also completed, but when section A of the resident’s MDS submissions was completed, PASRR information was overlooked because the system pre-populated demographic information. Record review showed the resident was admitted with diagnoses of Anxiety, Depression, Schizoaffective Disorder, and Cerebral Palsy, and had a Level One PASRR on file that qualified the resident for a Level Two screening, with recommended services received. Review of the resident’s MDS assessments showed section A was coded to indicate the resident was not considered to have serious mental illness and/or intellectual disability or a related condition using the State PASRR evaluation process, based on how the MDS was coded.
Failure to Ensure Safe Mechanical Lift Transfers Resulting in Resident Death
Penalty
Summary
A facility staff member failed to properly transfer a resident using a mechanical lift, resulting in a fall that caused significant injuries and ultimately contributed to the resident's death. The resident required total assistance for transfers, as documented in the care plan, which specified the use of a Hoyer lift with two staff members present. Despite this, the staff member performed the transfer alone, and during the process, one of the sling straps became unhooked, causing the resident to fall to the floor. The resident sustained a subdural hematoma, a C2 cervical fracture, and a forehead laceration, and passed away three days later, with the fall listed as a contributing factor on the death certificate. Interviews and record reviews revealed that the staff member who performed the transfer had not received orientation or a return demonstration on the use of mechanical lifts. She reported that it was common practice at the facility for CNAs to use the lifts alone, and that new staff were trained to do so. Other staff members corroborated that using mechanical lifts without a second person was a routine practice, and that straps had previously come unhooked during transfers. The staff member acknowledged knowing that two people were required for safe use of the lift but did not follow this protocol at the time of the incident. Additional staff interviews confirmed that the improper use of the mechanical lift was a known issue, with some staff reporting that they had observed or participated in single-person transfers despite the care plan and facility policy requiring two staff members. The incident was identified as an Immediate Jeopardy situation due to the risk of serious harm, and the deficiency was cited under F689 for failure to ensure the environment was free from accident hazards and that adequate supervision was provided to prevent accidents.
Failure to Follow Safe Mechanical Lift Practices Resulting in Resident Death
Penalty
Summary
Facility staff failed to protect a resident from neglect by not following safe lifting practices during transfers with a mechanical lift. Multiple staff interviews revealed that, despite being trained to use two staff members for mechanical lifts, the facility had adopted a practice of using only one staff member for these transfers. This change was attributed to reduced staffing levels following administrative decisions to decrease staff hours. The resident's care plan specifically required two staff members to assist with transfers using a Hoyer lift, but this directive was not followed. As a result of this failure, the resident, who was totally dependent on staff for transfers, fell from the Hoyer lift. The incident resulted in the resident being found on the floor with significant injuries, including a subdural hematoma, C2 cervical fracture, and a forehead laceration. The resident was transported to the hospital and died three days later. The cause of death was listed as a subdural hematoma due to a fall from a Hoyer lift.
Failure to Ensure Staff Competency in Mechanical Lift Use
Penalty
Summary
The facility failed to ensure that licensed nurses and certified nurse assistants received proper training and competency evaluation on the procedure and safety requirements for using mechanical lifts. Fifteen out of sixteen sampled staff members had not received this training, and documentation of mechanical lift competency was only available for one staff member. New staff reported that they did not receive any training from the Director of Nursing prior to working with residents and were instead oriented by other CNAs, who advised that mechanical lift transfers could be performed independently, contrary to standard safety protocols. Several staff members confirmed they had not completed mechanical lift competency evaluations prior to a resident fall incident, with some stating their last training was years ago during their initial certification. A review of records showed that only one staff member had documented mechanical lift training, and the facility could not provide evidence of training for the remaining licensed and certified nursing staff, including management staff with CNA certification. The deficiency was highlighted by an incident in which a resident fell from a mechanical lift, resulting in the resident being found on the floor with significant bleeding. The incident was staff-witnessed, and it was reported that the transfer was performed using a mechanical lift.
Failure to Ensure Safe Mechanical Lift Transfers Due to Inadequate Staffing
Penalty
Summary
The facility failed to administer care in a manner that ensured individualized and safe transfer procedures for a resident requiring total assistance. The resident's care plan specified the use of a Hoyer lift with two staff members for transfers but did not identify the appropriate sling size. On the date of the incident, the resident was found on the floor with significant bleeding after falling from a Hoyer lift. Documentation and interviews revealed that the transfer was performed by a single certified nurse assistant, contrary to the care plan and facility policy. Multiple staff interviews confirmed that it was common practice for certified nurse assistants to operate mechanical lifts independently, and that management was aware of this deviation from policy. Staff reported that this practice had been ongoing for over a year, largely due to reduced staffing levels following administrative decisions to decrease staff hours. The reduction in available staff made it difficult to consistently have two staff members present for mechanical lift transfers, directly contributing to the incident.
Failure to Follow Two-Person Mechanical Lift Protocol Due to Staffing Shortages
Penalty
Summary
The facility failed to ensure that services were provided according to professional standards regarding the safe use of mechanical lifts for one of eight sampled residents. The resident's care plan specified total dependence on two staff members for transfers using a Hoyer full body mechanical lift. Interviews with staff revealed that, despite being trained to use two staff for mechanical lifts, staff members sometimes performed transfers alone due to staffing shortages. Staff acknowledged awareness of the requirement for two-person assistance but reported that single-person transfers occurred when only one CNA was available per hall, and that this practice was not consistent with their training or facility policy.
Dietary Manager Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the dietary manager had completed a certification program approved by a national certifying body or possessed higher education in a related field, as required for the role. During a kitchen tour, no documentation of advanced training for the dietary manager was observed. Interviews with staff revealed that the dietary manager had not yet obtained certification and was only in the early stages of an online Certified Dietary Manager/Certified Food Protection Professional program, with no clear completion date identified. This issue had been ongoing since the previous survey, and the facility's own assessment acknowledged that the dietary manager was still working toward certification.
Failure to Identify and Prevent Elopement Risks on Secure Unit
Penalty
Summary
The facility failed to timely identify and address elopement risks for two residents living on the secure unit, resulting in multiple incidents where residents left the premises or a safe area without proper supervision. One resident with severe cognitive impairment experienced three separate elopements by climbing out of unsecured or inadequately secured windows. The facility did not complete elopement assessments until after all three incidents had occurred, and the baseline care plan did not initially identify elopement as a problem or include interventions to prevent it. Interventions such as window audits and monitoring devices were either ineffective or not implemented in a timely manner, and staff were not consistently aware of or able to identify elopement events. Staff interviews revealed a lack of understanding regarding what constitutes an elopement, with some staff not recognizing that a resident leaving through a window into a courtyard or other area without supervision was an elopement. Documentation was incomplete, with no nursing notes for some elopement events, and required post-elopement assessments and social services follow-up were not performed as outlined in facility policy. Observations showed that window security devices were either improperly installed, easily removed by residents, or not yet installed on all windows, leaving ongoing elopement hazards present in the secure unit. Another resident identified as at risk for elopement did not have this risk included in the baseline care plan, and interventions were minimal and not consistently implemented by staff. Observations showed this resident repeatedly attempting to exit the secure unit and interacting with unsecured windows, with staff failing to redirect or engage the resident as required by the care plan. The overall elopement prevention system was inadequate, with insufficient supervision, incomplete assessments, and a lack of effective interventions to ensure resident safety.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for multiple residents, as evidenced by incomplete, altered, or improperly documented forms. For one resident, a POLST form was found with identifying information obscured by white-out and missing required provider signatures, dates, and phone numbers, rendering the form invalid. The same resident's staff assessment and medication consent forms were also incomplete, with missing dates, signatures, and documentation of consent. Another resident had elopement assessments and evaluations that were not completed until several days after the observation dates, contrary to standard practice, as confirmed by staff interviews. A third resident's elopement evaluation was similarly delayed in completion. Additionally, a POLST form for another resident was left blank in all required provider fields. A review of a care plan for another resident revealed the inclusion of irrelevant and inappropriate information, such as personal references to staff members' spouses, which did not pertain to the resident's care or needs. Staff interviews confirmed that this information was intentionally added to draw attention to the need for care plan updates, rather than for clinical documentation. The facility's policy on confidentiality and documentation was reviewed, but no specific policy regarding POLST forms was provided during the survey.
Failure to Refer Resident for Required Level II PASRR Review
Penalty
Summary
The facility failed to refer a resident with newly evident or possible serious mental disorder or related condition for a Level II review as required. The resident had diagnoses including unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and bipolar disorder, as documented in the care plan and psychiatric progress notes. The psychiatric notes indicated changes in psychotropic medications due to symptoms such as impulsivity and delusions. Despite these changes and the presence of significant mental health diagnoses, staff responsible for coordinating Level I and Level II assessments did not complete a Level I screening for the resident until after the survey began, and a completed Level I was not provided by the end of the survey.
Failure to Develop Timely Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for four residents, as required by policy. Staff interviews revealed that the interdisciplinary team, responsible for care planning, sometimes did not complete baseline care plans on time, especially during busy periods or when multiple admissions occurred. The computer system had a template for care plans, but it was not always utilized promptly. Staff acknowledged awareness of the requirement but admitted that care plans were sometimes delayed or incomplete. Record reviews and observations showed that for several residents, critical care needs were not addressed in the baseline care plans within the required timeframe. For example, one resident's nutrition concerns were not added until several days after admission, another resident's risk for elopement and psychotropic drug interventions were not included promptly, and a third resident's baseline care plan only addressed advance directives and skin risk, omitting other immediate needs. Additionally, a resident with Alzheimer's disease and a high fall risk did not have these risks reflected in the baseline care plan until days after admission, despite assessments indicating the need. These omissions increased the risk of staff not providing necessary care and services due to the lack of timely and comprehensive baseline care plans.
Failure to Individualize and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement individualized, comprehensive care plans for two of sixteen sampled residents. For one resident identified as an elopement risk, the care plan did not specify that the resident lived on a secure unit, nor did it include interventions or approaches to prevent elopement, despite the resident being observed daily in the secured unit. For another resident, the care plan only included a general directive to encourage participation in activities, without identifying the resident's specific interests or addressing her frequent episodes of crying. Staff were unaware of the resident's activity preferences and were observed to be unsure of how to effectively engage her or respond to her emotional distress. Additionally, the care plan for the second resident did not address significant family dynamics, including the potential for family members to remove the resident from the facility against medical advice. Nurse's notes documented an incident where family members attempted to take the resident out of the facility, and the physician instructed staff to contact the police if this occurred. However, the care plan lacked any guidance for staff on how to manage such situations, leaving them without direction in the event of future incidents.
Failure to Provide Individualized and Meaningful Activities for Residents
Penalty
Summary
The facility failed to provide meaningful and individualized activities to meet the preferences and interests of two residents. One resident was repeatedly observed pacing the halls and attempting to exit the secured unit without staff intervention or engagement, despite care plan instructions to redirect, distract, or offer activities, snacks, or conversation. Staff were present but did not attempt to involve the resident in activities or address the resident's behaviors. The resident's care plan only included a general reminder for activities and did not specify the resident's preferences for music, books, or magazines, even though these were noted as somewhat important in the assessment. Another resident was observed sitting passively and not engaged while a staff member painted a car, and other residents at the table were either unresponsive or not participating. Staff interviews revealed that CNAs were responsible for both resident monitoring and activities, often with only one CNA present on the secured unit. Staff admitted to not knowing individual resident preferences and not including individualized activity information in care plans. Activity assessments were limited to standard MDS questions, and staff relied on trial and error to determine resident interests.
Failure to Assess and Document Bed Rail Risks and Benefits
Penalty
Summary
The facility failed to adequately review and document the risks and benefits associated with the use of grab/assist bars attached to the beds for two residents. Observations revealed that one resident had a grab bar on the left side of the bed, while another had grab bars on both sides. Interviews with staff indicated that one resident did not use the side rails during personal care or transfers, and only occasionally used the assist bar when sitting on the edge of the bed. The same resident was noted to have severe cognitive impairment, visual impairments, problems with balance and trunk control, and was taking psychotropic medications, all of which require safety precautions. However, the assessment and consent documentation did not address how the resident's restlessness and other risk factors could impact safety in relation to the grab bars. For the second resident, staff confirmed that the resident requested the side rails be reinstalled after removal, but no alternative interventions were attempted prior to their use. The assessment did not consider entrapment hazards related to the resident's weakness, nor was there evidence of scheduled maintenance or safety measurements for the bed and grab bars. The resident also had severe cognitive impairment and was taking multiple psychotropic medications, but the effects of these medications were not documented as part of the side rail assessment. The facility's failure to thoroughly assess and document the risks and benefits, as well as to consider alternative interventions, led to the deficiency.
Failure to Notify Family and Provider of Elopement Details
Penalty
Summary
The facility failed to notify a resident's provider and family member about the details of an elopement incident involving a resident with severe cognitive impairment, as indicated by a BIMS score of 4. The facility's policy on elopement and wandering residents requires that a nurse perform a physical assessment and report findings to the physician, with any new physician orders communicated to the family or authorized representative. However, in this case, the facility did not inform the resident's family or provider about the 12-hour period during which the resident was absent, including the fact that the resident was taken to a stranger's cabin overnight before being returned to the facility. Interviews with staff and family members revealed that the lack of communication prevented necessary medical evaluations and decisions from being made. Family members and staff stated that had they been informed of the full circumstances, they would have taken additional steps, such as ordering an assault kit and further exams for the resident. The failure to communicate these critical details was acknowledged by staff, who confirmed that it was expected for such events to be reported to both the provider and the family.
Failure to Conduct Comprehensive Assessment Post-Elopement
Penalty
Summary
The facility failed to conduct a comprehensive physical assessment of a resident following an elopement incident, which had the potential for harm related to sexual trauma. The resident, who had a severe cognitive impairment with a BIMS score of 4, was found by a construction worker in his car and was taken to his RV park cabin to sleep. The next morning, the worker realized the resident was confused and returned her to the facility. Upon her return, the resident was not sent for a comprehensive physical or sexual assault examination, despite spending the night at a stranger's cabin. Interviews with staff revealed that there was a lack of communication and adherence to the facility's post-elopement procedures. Staff members were waiting for guidance from the police department and did not follow the policy to send the resident for further examination. The facility's policy required a nurse to perform a physical assessment and report findings to a physician, which was not fully executed. Staff members expressed concerns about the resident's inability to give sexual consent and the absence of a complete physical assessment to rule out sexual assault.
Failure to Secure Memory Unit and Monitor Resident Leads to Elopement
Penalty
Summary
The facility failed to secure the memory unit and adequately monitor a cognitively impaired resident with a known history of elopement attempts. This resulted in the resident leaving the building unsupervised overnight. The incident occurred when the resident exited through the memory lane dining room door, which did not alarm, and then through a fence gate that also failed to alarm. The resident was later found across the road at an RV park, inside someone's cabin, sleeping on a couch. Interviews with staff revealed that the dining room door alarms in the memory unit had been broken for approximately two weeks before the elopement. Staff were aware of the broken door and had attempted to secure it with a temporary childproof lock, which was not effective. The gate alarm required specific steps to activate, and many staff were not trained to set it. The facility's camera footage confirmed that no alarms were heard during the resident's elopement, and no staff were present at the time. The resident involved had a severe cognitive impairment, with a BIMS score of 4, and a history of exit-seeking behavior. The resident's care plan indicated a risk of elopement, with previous incidents of exiting the memory care unit and eloping through a window. The facility's policy on elopements and wandering residents stated that door locks and alarms were in place to prevent such incidents, but these measures were not effectively implemented in this case.
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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.
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Nursing homes near Wibaux
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eastern Montana Veterans Home | 25.6 mi | ★★★★★ | 2 | 0 |
| Glendive Medical Center N H | 25.8 mi | ★★★★★ | 20 | 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 August 2026) and official state health department websites.