The resident was found lying on her right side with the right side of her face against the floor and a large amount of blood pooled around her, according to a nursing progress note from September 10. The certified nursing assistant reported it was a staff-witnessed fall from the Hoyer lift.
Federal inspectors discovered that 15 of the facility's 16 sampled staff members had never received proper training on mechanical lift procedures and safety requirements. Seven residents at the 30-bed facility still require mechanical lifts for transfers.
The training gaps created dangerous conditions. A newly hired certified nursing assistant identified as NF1 told inspectors she started working about a month before the inspection and received no training from the Director of Nursing before working directly with residents. During her orientation, other CNAs told her that residents requiring mechanical lifts didn't need two staff members to assist — she could perform transfers alone.
"The other certified nurse assistants said they also complete the lift transfers independently," NF1 told inspectors during a September 22 interview.
Staff member H revealed she had not received mechanical lift training or completed competency evaluations before September 11 — one day after the resident's fall and major injuries. Her last mechanical lift competency was completed years earlier during her state certification exam.
The facility's own education coordinator, staff member C, acknowledged that nursing staff competencies for mechanical lifts were supposed to be completed in May 2025, requiring staff to perform return demonstrations of proper lift use.
But records told a different story.
When inspectors reviewed staff education documents, they found only one employee — staff member O — had actually received mechanical lift training on May 30, 2025. Staff member C could produce just one mechanical lift competency form for staff member O and no training documents for any other licensed nurses, certified nursing assistants, or the two management staff members who maintained their CNA certifications.
The training failure left vulnerable residents at risk during one of the most dangerous daily care activities. Mechanical lifts are essential equipment for residents who cannot transfer independently, but improper use can result in falls, injuries, and death.
The September 10 incident involving the resident who fell from the lift occurred during what the CNA described as a "staff witnessed fall." The nursing progress note documented the resident lying injured with significant bleeding, but the inspection report provided no additional details about the extent of injuries or medical treatment required.
Federal regulations require nursing homes to ensure all staff members have appropriate competencies to care for residents in ways that maximize their well-being. The widespread lack of mechanical lift training at Wibaux County Nursing Home represented a fundamental failure to meet this basic safety requirement.
The deficiency affected not just individual staff members but created systemic risk throughout the facility. With seven residents still requiring mechanical lifts and only one properly trained staff member documented, the potential for additional accidents remained high.
Staff member C's inability to produce training records for nearly all employees suggested the facility's education system had broken down completely. The May 2025 competency requirements existed on paper but were never implemented in practice.
The timing proved particularly troubling. The resident's fall and injuries occurred in September, four months after the facility's own coordinator said mechanical lift competencies should have been completed. The gap between policy and practice left residents vulnerable for months.
NF1's experience illustrated how dangerous misinformation spread among untrained staff. Rather than receiving proper instruction from supervisors, she learned incorrect procedures from other CNAs who also lacked training. The practice of single-person mechanical lift transfers, which she was taught during orientation, violated basic safety protocols.
The facility's failure extended beyond individual competency to institutional accountability. Management staff who retained CNA certifications also lacked current mechanical lift training, suggesting oversight failures reached the highest levels of facility operations.
For the seven residents who depend on mechanical lifts for basic mobility and transfers, the training deficiencies created daily risk. Each transfer became a potential accident waiting to happen, performed by staff who learned procedures through informal word-of-mouth rather than proper instruction and demonstration.
The resident found bleeding on the floor after falling from the lift represents the human cost of these training failures — a vulnerable person injured during routine care that should have been safe.
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.