Inspection Reports for
Wibaux County Nursing Home

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: the facility failed to protect resident #1 from neglect by not employing safe mechanical lift practices requiring two staff, resulting in a fall and serious injury.

F 0658 Ensure services provided by the nursing facility meet professional standards of quality: the facility failed to provide safe mechanical lift services for resident #1 by allowing single-person lifts contrary to care plan requirements.

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to ensure two staff assisted with mechanical lifts, resulting in resident #1 falling from the lift, sustaining a subdural hematoma, C2 cervical fracture, and death.

F 0726 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: the facility failed to provide adequate training and competency evaluation on mechanical lift use to licensed and certified staff, increasing risk of harm.

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently: the facility failed to administer staffing and training to ensure resident #1 received individualized care and safe mechanical lift use, contributing to a fall and death.

F 0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted: the facility failed to develop baseline care plans within 48 hours for multiple residents, omitting key risk factors such as elopement and fall risks, and did not include necessary interventions in the plans.

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured: the facility failed to develop individualized comprehensive care plans for residents, lacking specific interventions for elopement risk and behavioral issues such as frequent crying.

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to timely identify elopement risks and implement effective interventions for residents at risk, including inadequate window security and insufficient supervision, resulting in multiple elopements.

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards: the facility failed to maintain accurate, complete, and properly documented medical records for several residents, including incomplete POLST forms, delayed completion of elopement assessments, and inappropriate documentation in care plans.

F0644 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed: the facility failed to refer a resident with a possible serious mental disorder for a Level II review in a timely manner.

F0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted: the facility failed to ensure baseline care plans were developed and implemented within 48 hours for multiple residents, missing key risk factors and interventions.

F0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured: the facility failed to develop individualized comprehensive care plans addressing elopement risks and emotional needs for sampled residents.

F0660 Plan the resident's discharge to meet the resident's goals and needs: the facility failed to implement effective discharge planning for a resident discharged to another long-term care facility, lacking documentation and communication of elopement risk.

F0679 Provide activities to meet all resident's needs: the facility failed to provide meaningful activities tailored to resident preferences and interests for sampled residents, resulting in unengaged and pacing behaviors.

F0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to timely identify elopement risks and implement sufficient interventions for residents at risk, including inadequate window security and inconsistent supervision.

F0700 Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail: the facility failed to review risks and benefits of grab bars attached to beds for two residents, lacking proper assessments and consideration of psychotropic medication effects.

F0801 Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician: 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.

F0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards: the facility failed to maintain accurate, complete, and properly documented medical records for multiple residents, including incomplete POLST forms, delayed assessments, and inappropriate documentation in care plans.

F 0580 Immediately tell the resident, the resident's doctor, and a family member of situations that affect the resident: the facility failed to notify a resident's provider and family member of the events surrounding an elopement, preventing necessary medical decisions.

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: the facility failed to complete a comprehensive physical and sexual assault assessment after a resident eloped and stayed overnight at a stranger's cabin.

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to secure the memory unit and monitor a cognitively impaired resident with a known history of elopement attempts, resulting in the resident leaving unsupervised overnight.

F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely: the facility failed to maintain cleanliness in resident #17's room and common areas, with debris on floors, dirty toilets, dusty vents, stained ceiling tiles, and malodorous rooms over multiple days.

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing: the facility failed to provide consistent and timely care for resident #14's pressure ulcers, including lack of pressure relieving cushions, delayed physician orders, and no re-evaluation of nutrition after ulcer development.

F 0801 Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician: dietary staff lacked required certifications and supervision, with the acting supervisor performing multiple roles and expired certifications.

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: the facility failed to properly date and label food items, allowed food handlers to touch food with contaminated gloves, and did not enforce hair/beard restraints in the kitchen.

F 0741 Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents: the facility failed to provide adequate staffing on the memory care unit, resulting in multiple elopements, inadequate incontinence care, unsupervised wandering, and physical aggression among residents.

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment: the facility failed to transmit MDS data within 14 days for 6 of 15 sampled residents.

F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: the facility failed to revise the care plan to include interventions to prevent behaviors causing disturbances and physical aggression for one sampled resident.

F 0741 Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents: the facility failed to provide sufficient staffing on the memory unit to prevent elopements, provide incontinence care, and manage physical aggression and wandering for several sampled residents.

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia: the facility failed to ensure one sampled resident received care to attain or maintain their highest level of functioning, including individualized interventions for incontinence and dementia care.

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs: the facility failed to remove expired medications and supplies from the medication storage room.