Wibaux County Nursing Home

F 0600

-C2 cervical fracture

Level of Harm - Actual harm

- Fall in her home (the facility)

Residents Affected - Few

-Forehead laceration.

Review of resident #1's Montana Certificate of Death, dated [DATE REDACTED], showed resident #1 died on [DATE REDACTED] at 6:10 a.m., which was three days after the fall with significant injuries. The Montana certificate of death listed

the causes of death as: - a subdural hematoma - fall from a Hoyer lift.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Wibaux County Nursing Home

712 Wibaux St S Wibaux, MT 59353

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658

Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or potential for actual harm

Based on interviews and record review the facility failed to ensure services were provided according to professional standards related to safe use of mechanical lifts for 1 (#1) of 8 sampled residents. Review of resident #1's care plan, dated 8/5/22, showed that resident #1 was totally dependent upon two staff members for transferring her from surface to surface. The care plan directed the staff to use a Hoyer fully body mechanical lift. During an interview on 9/22/25 at 2:01 p.m., NF1 had not used a mechanical lift by themself before working at the facility, and stated, I knew I should have a second person because I was trained and have always had two people for lifts. During an interview on 9/22/25 at 2:32 p.m., staff member H said she was taught to use two people when using a mechanical lift to transfer people. Staff member H said she had used the lift by herself. Staff member H said she was aware that only using one person for transferring residents with a mechanical lift was not the right way to provide the care. Staff member H said it upset her when the staffing was changed to having only one CNA in each hall. Staff member H said the residents had to get taken care of, so We had to do what we could to get the residents taken care of, and that included using the mechanical lifts by ourselves. During an interview on 9/23/25 at 10:39 a.m., staff member L said he had training on the lifts in the past. Staff member L said he had been using lifts for a long time, so he knows how to use them. Staff member L said it was never 100% for getting two staff to help.

Staff member L said most of the time he had two staff doing the lifts, but sometimes the facility is short-staffed and two staff are not always available.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Wibaux County Nursing Home

712 Wibaux St S Wibaux, MT 59353

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

an interview on [DATE REDACTED] at 3:02 p.m., staff member S said he saw resident #1 in the hospital the second day

she was there. Staff member S said resident #1 had a subdural hematoma and fractures of the Cervical spine at level C1-C2. Staff member S said the fractures of C1-C2 were unstable, but there was no spinal cord involvement and no spinal cord dissection. Staff member S said he did not complete the death certificate, but the cause of death would likely be from subdural hematoma, closed head injury, and concussion. Staff member S said the cause of death was definitely related to the fall from the lift.During an

interview on [DATE REDACTED] at 2:17 p.m., staff member E said she watched the hallway camera video of the fall which occurred on [DATE REDACTED] at approximately 6:00 p.m. Staff member E said she saw NF1 stick her head out of the door (of #1's room). Staff member E, and another staff member went into resident #1's room, and

she could see one of the shoulder straps was not connected to the lift. During an interview on [DATE REDACTED] at 2:40 p.m., staff member F said she was the nurse on duty at the time resident #1 fell and was injured. Staff member F said she could tell resident #1 was hurt; most of the damage was on her right side, which she was lying on. Resident #1's eye socket was swollen, and she was bleeding from a laceration on her forehead. The staff did not move her, and the ambulance arrived quickly. Staff member F said NF1 had transferred resident #1 by herself with the mechanical lift. Staff member F said some of the CNAs said staff member C allowed the staff to transfer residents using the mechanical lifts by themselves without a 2nd person to assist for safety.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Wibaux County Nursing Home

712 Wibaux St S Wibaux, MT 59353

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Based on interview and record review, the facility failed to ensure licensed nurses and certified nurse assistants received training on the procedure and safety requirements for using mechanical lifts for fifteen (D, E, F, G, H, I, J, K, L, M, N, P, Q, R, NF1) of sixteen sampled staff members. The deficient practice increased the risk of harm for the seven residents in the facility still utilizing a mechanical lift. The facility reported a census of 30. Findings include: During an interview on 9/22/25 at 2:01 p.m., NF1 said she started her job at the facility about a month ago. NF1 said the Director of Nursing did not complete any training with her prior to working directly with residents. NF1 said upon hire she signed some paperwork and then trained directly with a certified nurse assistant during orientation. NF1 said during orientation the CNAs who trained her said a resident who required the use of a mechanical lift did not require two staff to assist, and NF1 could perform the task independently. NF1 said the other certified nurse assistants said

they also complete the lift transfers independently. During an interview on 9/22/25 at 2:32 p.m., staff member H said she did not receive training or complete a competencies evaluation related to mechanical lifts and their use of them for transferring residents, prior to 9/11/25, which was after resident #1 fell from

the mechanical lift and sustained major injuries. Staff member H said her last mechanical lift competency was completed years ago, which was when she completed her state exam for the certification. During an

interview on 9/22/25 at 2:55 p.m., staff member C said nursing staff competencies related to mechanical lift education were completed in May 2025, which was when nursing staff were required to perform a return demonstration of the mechanical lift use.Review of staff education, specifically related to mechanical lifts and their use, showed only staff member O received the mechanical lift training on 5/30/25. Staff member C provided one mechanical lift competency form for staff member O. Staff member C could not produce any more mechanical lift competency training documents for the rest of the licensed or certified nursing staff, and or the two management staff, who retained their CNA certification. Review of resident #1's nursing progress note, dated 9/10/25 at 6:44 p.m., showed, . Upon arrival to the room, resident seen lying on her right side with right side of face on floor and large amount of blood noted on the floor around the resident.

CNA reported resident fell from the hoyer lift in a staff witnessed fall. [sic]

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Wibaux County Nursing Home

712 Wibaux St S Wibaux, MT 59353

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Minimal harm or potential for actual harm

Based on interviews and record review the facility failed to ensure the facility was administered in a manner that allowed resident #1 to be provide individualized care related to mechanical lifts and falls and failed to promote the well-being and prevent physical harm, pain and death for 1 (#1) of 10 sampled residents.

Findings include: Review of resident #1's care plan dated 8/5/22 showed the resident #1 needed total assistance when transferring from surface to surface. The care plan directed the staff to use a Hoyer lift with two staff members. The care plan failed to identify the size sling to be used for resident #1. Review of resident #1's nurses note dated 9/10/25 at 6:44 p.m., showed resident #1 was seen lying on her right side with the right side of her face on the floor and a large amount of blood noted on the floor around the resident. The certified nurse assistant reported the resident fell from the Hoyer lift. Emergency medical services were on the scene at approximately 6:15. Resident #1 was transported to a local hospital. During

an interview 9/23/25 at 2:40 p.m., staff member F said she was the nurse on duty at the time resident #1 fell and was injured. Staff member F said she could tell resident #1 was hurt. Staff member F said the certified nurse assistant transferred resident #1 by herself. Staff member F said some of the certified nurse assistants told her staff member C was aware the certified nurse assistants were doing independent lifts and staff member C allowed the staff to transfer residents using the mechanical lifts by themselves with no help. During an interview of 9/22/25 at 2:01 p.m., NF1 said she was trained and oriented by the other certified nurse assistants. NF1 said the other certified nurse assistants trained her to only have one staff member present during the mechanical lift transfers. During an interview on 9/22/25 at 2:48 p.m., staff member D said the certified nurse aides use the mechanical lifts independently. Staff member D said the management was aware the lifts were being used by one person, and the policy was not being followed.

During an interview on 9/23/25 at 2:00 p.m. staff member H said the staff have been doing mechanical lifts without a second person in attendance. Staff member H said the practice of not having two staff member help with lifts had been going on for over a year and probably longer.During an interview on 9/23/25 at 2:33 p.m., staff member C said when the census went down, the administration and the board made the facility decrease staff hours. Staff member C said this caused a change in the staffing level to include one certified nurse assistant in the front and one certified nurse assistant on the locked dementia unit. Staff member C said the staff could not always find two staff to help during that time. Staff member C said she could not remember the exact time and said between March and July of 2025.

Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet