Wibaux County Nursing Home

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of neglect was reported to the State Survey Agency within the required timeframe for 1 (#13); failed to ensure allegations of abuse by staff were reported to the administrator and State Survey Agency within the required timeframe for 3 (#s 12, 19, and 25) of 6 residents sampled for abuse and neglect reporting. The failures placed the residents at risk for continued abuse or neglect and delayed investigation and intervention by the State Survey Agency.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan, which included the minimum necessary instructions needed to provide effective and person-centered care of a resident for 1 (#2) of 13 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise a care plan to reflect a resident's current care needs for 1 (#1) of 13 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff documented wound care, wound status, and dressing changes in accordance with professional standards of practice for 1 (#4) of 3 residents sampled for wounds. The failure placed the resident at increased risk for ineffective wound healing, undetected changes in condition, and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services to maintain a resident's quality of life for personal dignity, comfort, and safety for 1 (#13) of 13 sampled residents. The failure resulted in the resident remaining in vomit-soiled conditions for an extended period of time. The resident refused care and was periodically checked on by staff, but did not receive the level of care or assessment necessary related to her emesis episodes or risks related to them.

Inspectors wroteBased on interview and record review, the facility failed to implement an effective antibiotic stewardship program, including monitoring of antibiotic use within the facility. The failure placed residents at increased risk for inappropriate antibiotic use, adverse drug reactions, and development of antibiotic-resistant organisms.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete multiple comprehensive Minimum Data Set (MDS) assessments for the resident's Pre-admission Screening and Resident Review (PASRR), for 1 (#12) of 13 sampled residents.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the dietary manager completed a certification program approved by a national certifying body or had higher education in a related field. This had the potential to affect residents and their nutritional status or meal safety for those who consumed food prepared and served by the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to timely identify elopement risks, and implement sufficient preventative interventions for residents with elopement(s), for 2 (#s 20 and 23) residents of 2 sampled for elopements who lived on the secure unit. There continued to be elopement hazards, and it was identified necessary staff were not aware of how to identify an elopement, staff failed to use interventions to prevent elopements, and one resident had repeated elopements and was at high risk of eloping. The overall elopement system was not adequate to ensure resident safety.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records which were accurately documented, dated, labeled, and completed in their entirety, for 5 (#s 4, 14, 18, 20 and 23) of 16 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to refer a resident with a newly evident or possible serious mental disorder or related condition for a Level II review, for 1 (#3) of 16 sampled residents. This failure put the resident at risk for not receiving services necessary for mental health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours after admission to reflect the residents' care needs, for 4 (#s 20, 23, 24, 77) of 16 sampled residents. This increased the risk of staff not providing necessary care and services due to the lack of the baseline care plan.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement individualized comprehensive care plans for 2 (#s 12 and 24) of 16 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to implement an effective discharge planning process for 1 (#26) of 1 sampled resident, who was discharged to another long-term care facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide meaningful activities, designed to meet the individual resident preferences and interests, for 2 (#s 20 and 23) of 16 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to review the risks and benefits of using grab/assist bars attached to the bed, for 2 residents (#s 4 and 12) of 16 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to notify a resident's provider and family member of the events surrounding an elopement, so they may have made the necessary medical decisions for the resident following the elopement for 1 resident (#1) of 6 sampled residents. This deficient practice had the potential to affect all residents who require informed care from family and medical providers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a comprehensive physical assessment to ensure the patient's physical and sexual health remained intact after an elopement which had the potential for harm of the resident related to sexual trauma, and to become withdrawn from regular activities for 1 (#1) of 6 sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to secure the memory unit and monitor a cognitively impaired resident with a known history of elopement attempts, which resulted in the resident leaving the building unsupervised overnight, putting the resident at risk for serious injury or death, for 1 (#1) of 6 sampled residents.

Inspectors wroteBased 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.

Inspectors wroteBased on observations and interviews, the facility failed to ensure dietary staff were qualified to perform the duties necessary to manage the dining services department which increased the risk of a negative outcome related to nutrition for all residents who consumed food prepared and served by the facility's dietary department.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety. This deficient practice had the potential to affect all residents receiving food from the dietary department.

Inspectors wroteBased on observation and interview, the facility failed to provide a clean resident room for 1 (#17) of 16 sampled residents, and failed to provide a clean environment, including the hallways and television room, which may affect all residents using the unclean areas.