Wibaux County Nursing Home: Hoyer Lift Death - MT
The death certificate, reviewed by inspectors, was direct: the resident, identified in federal records as Resident 1, died at 6:10 a.m., three days after the fall. The certificate named two causes. A subdural hematoma, bleeding between the brain and its protective covering, caused by the impact. And the fall from a Hoyer lift, the mechanical sling device used to transfer residents who cannot move themselves, as the event that set everything in motion.
She had also fractured her C2 vertebra, the second bone from the top of the spine, one of the most dangerous injuries a person can sustain. A forehead laceration was documented as well. These were not minor injuries accumulated over time. They were the injuries of a single event, a fall that happened inside a place she lived, while staff were using equipment designed to keep her safe during a transfer.
A Hoyer lift is not a complicated piece of equipment in concept. A sling is fitted around the resident. The lift raises them. They are moved. They are lowered. The device exists precisely because the alternative, manual transfers, carries its own risks of injury for both residents and staff. When a Hoyer lift is used correctly, the resident does not fall. When a resident with a C2 fracture and a subdural hematoma dies three days after a Hoyer lift transfer, the question inspectors are obligated to ask is what went wrong during that transfer, and whether the facility took any meaningful steps to find out.
The federal deficiency cited is F0600, the tag covering abuse, neglect, and exploitation. Inspectors marked the level of harm as actual harm, not potential harm, not a paperwork problem. Actual harm. The deficiency notation describes the fall as having occurred in "her home," the facility's own characterization of itself, a phrase that carries particular weight when the home is where a resident suffered a fatal injury.
Wibaux County Nursing Home is a small facility in a small town. Wibaux, Montana sits in the far eastern corner of the state, close to the North Dakota border, with a population that rarely exceeds 400 people. The nursing home, at 712 Wibaux Street South, is the kind of facility that serves a community where there is no other option nearby, where families place their relatives knowing there is no competing facility down the road to choose instead. That context does not excuse what inspectors found. It does explain why the loss of a single resident carries a particular weight in a place this size, and why the question of whether this facility is operating safely matters to people who have no alternative.
The inspection was triggered by a complaint, not a routine survey. Someone reported what happened. Inspectors came. They reviewed the death certificate. They documented the fracture, the laceration, the bleeding in her brain, the three days between the fall and her death. They cited the facility for actual harm under the abuse and neglect standard.
What the inspection report does not contain is an explanation of how the fall happened. It does not describe what staff members were present during the transfer, what position the sling was in, whether the lift was inspected before use, whether the resident was properly secured, whether anyone saw the moment she fell. Those details, if they were gathered, are not in the public record of this inspection. What is in the record is the outcome: a woman with a C2 cervical fracture and a forehead laceration who died three days later of a subdural hematoma, and a federal finding that the facility bears responsibility for that harm.
A subdural hematoma after a fall is not an unusual injury in elderly residents. The brain, as people age, can shrink slightly within the skull, stretching the veins that bridge the brain to its outer covering. A fall, even one that might seem survivable, can tear those veins. Blood accumulates. Pressure builds against the brain. Without surgical intervention, or sometimes even with it, the pressure becomes fatal. A C2 fracture compounds everything. The second cervical vertebra is close enough to the brainstem that injuries there can affect breathing, circulation, and basic neurological function. Surviving both injuries, in an elderly nursing home resident, is not guaranteed. She did not survive.
The inspection record marks the residents affected as "few," the CMS designation for a deficiency that did not spread across the resident population. In this case, that is not a mitigating fact. It is simply an acknowledgment that the harm was concentrated in one person. One person who fell. One person who fractured her neck. One person who bled into her brain. One person who died.
Federal inspectors completed this complaint investigation on September 24, 2025. The deficiency was cited at a scope and severity level consistent with actual harm to a limited number of residents. The facility's plan of correction, if one has been submitted, is not available through the public inspection record and would need to be obtained directly from the facility or the Montana state survey agency.
What is available is the death certificate. A legal document, signed and filed with the state of Montana, that identifies the cause of death as a subdural hematoma and names the fall from a Hoyer lift as the event that caused it. Death certificates are not inspection findings. They are not allegations. They are the state's official record of how a person died. This one says she died because she fell from a mechanical lift in a nursing home, in a room she lived in, on a day when staff were trying to move her from one place to another.
Her name is not in the public inspection record. She is Resident 1 in federal documents, a designation that strips away the specifics of who she was, how long she had lived at Wibaux County Nursing Home, what her family knew and when they knew it, what they were told about the fall and what they were not told. Those details belong to a family in a small Montana town that is now without someone they placed in a facility because they believed she would be cared for there.
The Hoyer lift that was supposed to keep her safe did not.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wibaux County Nursing Home from 2025-09-24 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 13, 2026 · Our methodology
WIBAUX COUNTY NURSING HOME in WIBAUX, MT was cited for violations during a health inspection on September 24, 2025.
The certificate named two causes.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.