Caribou Healthcare Center, LLC

Inspectors wroteBased on interviews, observations, and record review, the facility failed to promote care for all residents in a manner that maintains each resident's dignity and respect during repositioning, bed mobility, and activities of daily living [ADL] care for 1 of 1 resident reviewed for resident rights (Resident #9 [R9]).

Inspectors wroteBased on review of reportable incident forms, clinical record review, facility policies, and interviews, the facility failed to ensure that 3 of 4 residents reviewed for falls (Resident #1, #3, and #4) were free from accident hazards and provided with supervision and assistance devices to prevent accidents, resulting in 3 avoidable falls, with major injuries to 2 residents. Specifically, the facility staff failed to maintain the required extensive assistance for Resident #1 (R1) during peri-care, which caused R1, who had hemiplegia, to roll out of bed and sustain a displaced fracture of the right femoral neck upper thigh bone. Additionally, staff failed to ensure the correct and safe use of assistive devices for two other residents: staff failed to attach footrests during R3's wheelchair transport, causing R3 to fall forward and sustain a nasal bone fracture; [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure that medications and medical equipment were stored properly by having an unlocked, unattended medication cart on 1 of 3 days (A wing medication cart) (6/30/25), and a treatment cart on 2 of 3 days of survey (7/1/25, and 7/2/25) allowing residents and unauthorized people access to medications, and medication equipment.

Inspectors wroteBased on review of the facility's water management program and interview, the facility failed to fully develop/implement a water management program to prevent the growth and spread of legionella and other water-borne pathogens.

Inspectors wroteBased on observation and interviews, the facility failed to promote care for all residents in a manner that maintains each resident's dignity and respect during resident transportation on 1 of 3 days of survey (7/1/25) and during meal services on 1 of 3 days of service (6/30/25).

Inspectors wroteBased on observation, interviews, and record review, the facility's interdisciplinary team meeting (IDTM) group failed to determine if it was clinically appropriate for a resident to keep medications at bedside and self-administer a medicated powder topically for 1 of 1 Residents observed with a medicated powder at bedside (Resident #165 [R165]).

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's right to formulate an advance directive regarding cardiopulmonary resuscitation (code status) was clear in the clinical record for 1 of 9 sampled residents reviewed for advanced directives (Resident #214 [R214]).

Inspectors wroteBased on record review and interview, the facility failed to review, revise and update a care plan for a newly discovered pressure ulcer for 1 of 1 resident reviewed for pressure ulcer (Resident #19 [R19]).

Inspectors wroteBased on record reviews and interview, the facility failed to follow physician orders for 1 of 3 residents reviewed for use of sliding scale insulin (Resident #49 [R49]).

Inspectors wroteBased on observation and interview, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety by not storing food in a sanitary manner for 2 of 3 days of survey (6/30/25 and 7/2/25).

Inspectors wroteBased on record reviews, Centers for Disease Control and Prevention (CDC) recommendations, and interviews, the facility failed to offer the updated Pneumococcal vaccination to 1 of 5 residents (Resident #24 [R24]).

Inspectors wroteBased on record review, review of the facility incident report, observation, and interviews, the facility failed to monitor an unlocked and/or non-alarmed door to prevent a resident identified as an elopement risk from leaving the building unnoticed. A staff member, who was informed by a visitor, told staff she saw a resident outside, unattended. The failure to have monitoring of unlocked, and/or non-alarmed doors, resulted in an avoidable elopement for 1 of 3 resident reviewed for elopement risk (Resident # 1 [R1]).

Inspectors wroteBased on observations and interviews, the facility failed to provide respiratory care consistent with professional standards of practice by failing to ensure that respiratory equipment was clean, for 3 of 3 days of survey for Resident #33 (R33), R13, R35, R24, and R48).

Inspectors wroteBased on observations and interviews, the facility failed to ensure expired medications were removed from the available for use supply, for 1of 2 Medication Carts reviewed (B Wing Medication Cart), and 2 of 2 Medication Storage Rooms reviewed (B Wing Medication Storage and C-D Wing Medication Storage).

Inspectors wroteBased on observations, and interviews the facility failed to maintain an Infection Control Program designed to help prevent cross contamination and/or development of infection by maintaining a safe and sanitary environment related to enhanced barrier precautions (EBP's) pertaining to Resident's with urinary Foley catheters for 3 of 3 days of survey (6/24/24, 6/25/24, and 6/26/24).

Inspectors wroteBased on record review and interview, the facility failed to transmit a quarterly Minimum Data Set (MDS) electronically to the State MDS database within 14 days of completion date for 1 of 1 system selected residents reviewed for Resident Assessment (Resident #14 [R14]).

Inspectors wroteBased on employee files review and interviews, the facility failed to develop and implement an education program that included annual training on the Infection Control program standards, policies, and procedures for 1 of 5 Certified Nursing Assistants (CNA) reviewed ( CNA1).

Inspectors wroteBased on facility reported incident and investigation review, record review, and interviews, the facility failed to ensure that a resident who was identified as a stand pivot transfer received assistance from two staff members during a transfer for 1 of 1 facility reported incidents reviewed (4/24/24).

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to provide residents a whirlpool/shower/shampoo as directed by the Resident's shower schedule for 5 of 5 residents reviewed for personal grooming care on A-Wing (Resident #30, Resident #35, Resident #44, Resident #45, and Resident #48).

Inspectors wroteBased on observations, interview and record reviews, the facility failed to ensure that the resident's environment was free of accident hazards and potential entrapment hazards by failing to complete a safety bed assessment prior to the use of bed bolsters for 8 of 16 sampled residents (Resident #19, Resident #23, Resident #28, Resident #39, Resident #42, Resident #45, Resident #48, Resident #49).

Inspectors wroteBased on interviews, and observation the facility failed to promote care for a resident in a manner that maintains each resident's dignity and respect when staff failed to provide appropriate perineal care (refers to caring for the genital and rectal areas of the body) for 1 of 5 residents interviewed pertaining to activities of daily living (ADL) care. (Resident #25)

Inspectors wroteBased on record review and interview, the facility failed to notify a Resident Representative of a resident fall with injury in a timely manner for 1 of 6 sampled residents that had falls. (#9).

Inspectors wroteBased on record reviews, interviews and observation, the facility failed to ensure that a physician's order for sliding scale insulin was followed for 1 of 3 sampled diabetic residents with an insulin sliding scale order (Resident #37). In addition, the facility failed to ensure that a physician order for continuous oxygen was followed for 1 of 1 sampled resident with oxygen (Resident #35).

Inspectors wroteBased on record reviews and interview, the facility failed to ensure an Abnormal Involuntary Movement Scale (AIMS), used to monitor for potentially irreversible side effects of anti-psychotic medications, was completed on admission for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #32).