Inspection Reports for
Wibaux County Nursing Home
710 South Wibaux St., Wibaux, MT, 59353
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
10.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
78% worse than Montana average
Montana average: 5.8 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 5
Date: Sep 24, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding neglect of care related to improper use of mechanical lifts during resident transfers, which resulted in a resident fall and serious injury.
Complaint Details
The investigation was triggered by a complaint regarding neglect and unsafe mechanical lift practices. The complaint was substantiated as the resident fell from a mechanical lift due to staff not following required two-person assistance policies, resulting in serious injury and death.
Findings
The facility failed to follow safe mechanical lift practices by allowing staff to transfer residents with a mechanical lift without the required two-person assistance, leading to a resident fall with serious injuries and subsequent death. Staff training and competency evaluations on mechanical lift use were inadequate, and staffing levels were reduced, contributing to unsafe practices.
Deficiencies (5)
Failure to protect resident from neglect by not employing safe mechanical lift practices with two staff members as required.
Failure to ensure services met professional standards related to safe use of mechanical lifts.
Failure to ensure nursing home area was free from accident hazards and provide adequate supervision to prevent accidents, resulting in immediate jeopardy.
Failure to ensure nurses and nurse aides received appropriate training and competency evaluation on mechanical lifts.
Failure to administer the facility in a manner that enabled individualized care and prevented harm related to mechanical lifts and falls.
Report Facts
Residents sampled: 8
Residents sampled: 16
Facility census: 30
Residents affected: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NF1 | Certified Nurse Assistant | Named in neglect and unsafe mechanical lift use leading to resident fall |
| Staff member H | Reported use of mechanical lifts without second person and assisted after resident fall | |
| Staff member C | Reported staffing changes and allowed use of mechanical lifts by one person | |
| Staff member L | Reported training and use of mechanical lifts, sometimes without two staff | |
| Staff member F | Nurse on duty | Witnessed resident injury and reported unsafe lift practices |
| Staff member S | Provided medical information on resident injuries and cause of death | |
| Staff member E | Reviewed hallway camera video of resident fall | |
| Staff member D | Reported management awareness of unsafe lift practices | |
| Staff member O | Only staff member documented to have completed mechanical lift training |
Inspection Report
Routine
Deficiencies: 4
Date: Mar 13, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to care planning, elopement risk management, accident prevention, and medical record maintenance at Wibaux County Nursing Home.
Findings
The facility failed to develop and implement baseline and comprehensive care plans timely and adequately for multiple residents, particularly regarding elopement risks and individualized care needs. Elopement risks were not properly identified or managed, resulting in multiple elopements. Medical records were incomplete, inaccurately documented, and contained inappropriate entries.
Deficiencies (4)
Failed to ensure baseline care plans were developed and implemented within 48 hours after admission for 4 of 16 sampled residents, increasing risk of inadequate care.
Failed to develop and implement individualized comprehensive care plans for 2 of 16 sampled residents, lacking timetables and measurable actions.
Failed to timely identify elopement risks and implement sufficient preventative interventions for residents with elopements, resulting in repeated elopements and inadequate supervision.
Failed to maintain medical records that were accurately documented, dated, labeled, and completed in their entirety for 5 of 16 sampled residents.
Report Facts
Residents sampled: 16
Residents affected baseline care plan: 4
Residents affected comprehensive care plan: 2
Residents affected elopement risk: 2
Residents affected medical record deficiencies: 5
Fall risk score: 19
Observation dates delayed: 14
Elopements: 3
Observation frequency: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff members A, B, C, F, G, H, I, N, and NF1 mentioned in interviews and observations related to care planning, elopement risk, and record keeping but no full names provided. | ||
| Staff member B | Involved in care plan development, elopement evaluations, and medication administration record reviews. | |
| Staff member C | Involved in care plan development and updating, including baseline care plans. | |
| Staff member G | Provided observations and interviews regarding resident #24 and elopement monitoring. |
Inspection Report
Routine
Deficiencies: 9
Date: Mar 13, 2025
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations at Wibaux County Nursing Home.
Findings
The facility was found deficient in multiple areas including failure to refer a resident for mental health Level II review, incomplete baseline and comprehensive care plans, inadequate discharge planning, insufficient meaningful activities, inadequate elopement risk identification and prevention, improper use and assessment of bed rails/grab bars, dietary manager lacking certification, and incomplete or inaccurate medical records.
Deficiencies (9)
Failed to refer a resident with a newly evident or possible serious mental disorder for a Level II review.
Failed to ensure baseline care plans were developed and implemented within 48 hours after admission for multiple residents.
Failed to develop and implement individualized comprehensive care plans for residents, lacking timetables and measurable actions.
Failed to implement an effective discharge planning process for a resident discharged to another long-term care facility.
Failed to provide meaningful activities designed to meet individual resident preferences and interests.
Failed to timely identify elopement risks and implement sufficient preventative interventions for residents at risk of elopement.
Failed to review risks and benefits of using grab/assist bars attached to beds for residents, including lack of safety assessments.
Dietary manager lacked certification from a national certifying body or higher education in a related field.
Failed to maintain medical records that were accurately documented, dated, labeled, and completed in their entirety.
Report Facts
Sampled residents: 16
Residents affected: 1
Residents affected: 4
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 2
Residents affected: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member B | Interviewed regarding care plans, elopement assessments, discharge planning, and documentation issues | |
| Staff member C | Interviewed regarding care plans, Level I and II completion, and documentation irregularities | |
| Staff member G | Interviewed regarding resident monitoring and activities on secured unit | |
| Staff member F | Interviewed regarding window security and elopement prevention | |
| Staff member H | Interviewed regarding resident elopements and activity provision | |
| Staff member K | Interviewed regarding resident care and use of grab bars | |
| Staff member M | Dietary Manager | Interviewed regarding lack of certification and ongoing training |
| Staff member N | Interviewed regarding care plan oversight and dietary manager certification status | |
| Staff member A | Interviewed regarding care plans, discharge planning, and documentation irregularities |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 14, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident elopement incident where the facility allegedly failed to notify the resident's provider and family, and failed to conduct a comprehensive physical assessment after the elopement.
Complaint Details
The investigation was triggered by a complaint related to a resident (#1) who eloped from the facility and was found the next day at a stranger's cabin. The complaint included failure to notify family and provider, failure to conduct proper assessments, and inadequate supervision and security measures. The resident had severe cognitive impairment and a history of exit seeking.
Findings
The facility failed to notify the resident's provider and family about the elopement and the events during the resident's absence, and failed to perform a comprehensive physical and sexual assault assessment after the resident spent the night at a stranger's cabin. Additionally, the facility failed to secure the memory unit doors and monitor the resident adequately, allowing the resident to elope unsupervised overnight.
Deficiencies (3)
Failed to notify resident's provider and family of events surrounding an elopement.
Failed to complete a comprehensive physical assessment to ensure patient's physical and sexual health after elopement.
Failed to secure memory unit and monitor cognitively impaired resident, resulting in unsupervised elopement overnight.
Report Facts
Residents sampled: 6
Resident BIMS score: 4
Elopement date and time: 1924
Duration resident missing: 12
Door alarm broken duration: 14
Search duration: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NF1 | Interviewed staff aware of elopement but not informed of details; stated resident unable to give sexual consent | |
| NF2 | Interviewed staff who spoke with individual who found resident and notified facility; stated assessment outside scope of practice | |
| NF3 | Interviewed staff who was told of elopement but not given details; would have ordered assault kit and exams | |
| Staff member N | Interviewed staff not made aware of events; would have sent resident for sexual assault exam | |
| Staff member D | Completed basic head-to-toe skin assessment; did not send resident for comprehensive exam | |
| Staff member E | Interviewed staff who described individual who found resident and took her to cabin | |
| Staff member M | Interviewed staff who described resident behavior and door alarm status | |
| Staff member O | Interviewed staff who stated gate alarms were not activated and staff not trained | |
| Staff member I | Interviewed staff who found resident missing and initiated search and notifications | |
| Staff member B | Interviewed staff aware of broken door and standard protocol for 24/7 coverage | |
| Staff member F | Interviewed staff who described temporary alarm and its failure |
Inspection Report
Routine
Deficiencies: 4
Date: Feb 29, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, environment cleanliness, pressure ulcer prevention and treatment, dietary services, and food safety at Wibaux County Nursing Home.
Findings
The facility was found deficient in maintaining a clean environment, providing appropriate pressure ulcer care, ensuring qualified dietary staff, and adhering to food safety standards. Specific issues included unclean resident rooms and common areas, delayed and inadequate pressure ulcer treatment, dietary staff lacking proper certification and supervision, and improper food storage and handling practices.
Deficiencies (4)
Failed to provide a clean resident room for 1 of 16 sampled residents and failed to maintain a clean environment including hallways and television room.
Failed to implement appropriate measures to prevent skin breakdown and provide consistent care, monitoring, and treatment of pressure ulcers for 1 of 16 sampled residents, resulting in development and worsening of pressure ulcers.
Failed to employ sufficient qualified dietary staff to manage dining services, increasing risk of negative nutrition outcomes for residents.
Failed to store, prepare, and distribute food in accordance with professional food service safety standards, including improper food dating, inadequate hygiene, and improper handling.
Report Facts
Sampled residents: 16
Residents affected by unclean environment: 1
Residents affected by pressure ulcer deficiency: 1
Pressure ulcer measurement: 2
Delay in treatment: 8
Nutrition supplement frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Interviewed about housekeeping staffing and cleaning practices related to unclean resident room | |
| Staff member L | Interviewed about housekeeping training and cleaning checklist | |
| Staff member I | Interviewed about mattress type on resident #14's bed | |
| Staff member G | Interviewed about mattress availability and use for resident #14 | |
| Staff member M | Interviewed about nutrition assessments for resident #14 | |
| Staff member C | Interviewed about dietary department staffing, certification, and food safety practices | |
| Staff member K | Observed preparing food without beard cover | |
| Staff member E | Interviewed about food and drink dating in unit refrigerators | |
| Staff member N | Observed wearing gloves and scratching head before handling food |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 1, 2023
Visit Reason
The inspection was conducted due to complaints regarding insufficient staffing on the memory care unit, which allegedly led to resident elopements, inadequate incontinence care, and behavioral disturbances.
Complaint Details
The visit was complaint-related, investigating incidents of resident elopements, inadequate care, and behavioral issues linked to insufficient staffing. The complaint was substantiated with multiple documented incidents of elopement and behavioral disturbances involving residents #8, #20, #19, and #129.
Findings
The facility failed to provide sufficient staffing on the memory care unit to prevent elopements for residents #8 and #20, and to provide scheduled toileting and incontinence care for resident #9. Insufficient staffing also resulted in physical aggression, unmonitored wandering, and disturbances among residents #19 and #129. Observations and interviews confirmed inadequate supervision and lack of individualized care plans and dementia care protocols.
Deficiencies (1)
Failure to provide sufficient staffing on the memory unit to prevent elopements and provide incontinence care.
Report Facts
Residents affected: 5
Facility Reported Incidents: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member B | Interviewed multiple times regarding resident care plans, staffing, and observations of resident behaviors. | |
| Staff member F | Observed as the only staff member present on the secure unit during several shifts, responsible for resident care and supervision. | |
| Staff member A | Provided information about staffing and resident behaviors, including one-to-one sitting for resident #129. | |
| Staff member H | Reported being alone on the secured unit most of the shift and described challenges with resident behaviors and staffing. |
Inspection Report
Routine
Deficiencies: 5
Date: Mar 1, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, staffing, dementia care, medication management, and safety in a nursing home facility.
Findings
The facility failed to timely transmit resident assessment data, revise care plans to address behavioral issues, provide sufficient staffing on the memory care unit, ensure individualized care for residents with dementia, and remove expired medications and supplies. Multiple residents exhibited behaviors such as elopement, aggression, and wandering, which were not adequately managed due to staffing shortages and incomplete care plans.
Deficiencies (5)
Failed to transmit Minimum Data Set (MDS) assessment data within 14 days for 6 of 15 sampled residents.
Failed to revise care plan to include interventions to prevent behaviors causing disturbances and physical aggression for 1 sampled resident.
Failed to provide sufficient staffing on the memory care unit to prevent elopements, provide incontinence care, and manage behaviors for sampled residents.
Failed to provide appropriate treatment and services to a resident with dementia to attain or maintain highest level of functioning.
Failed to ensure medications and supplies were removed and disposed of prior to expiration dates.
Report Facts
Residents sampled: 15
Residents with late MDS transmission: 6
Residents affected by staffing issues: 5
Outbursts by resident #129: 10
Outbursts during single staff shifts: 5
Expired medications and supplies observed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member B | Interviewed regarding MDS transmission delays, resident care plans, staffing, and medication expiration | |
| Staff member F | Observed and interviewed regarding staffing shortages and resident behaviors on secure unit | |
| Staff member A | Interviewed regarding resident behaviors and staffing on secure unit | |
| Staff member H | Interviewed regarding staffing and resident behaviors on secure unit | |
| Staff member D | Interviewed regarding medication expiration checks |
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