Caribou Healthcare Center, LLC

In the surveyor’s words

From the most serious findings on record at Caribou Healthcare Center, LLC, in the surveyor’s own words.

• Actual harm, patternF689Nov 5, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF761Jul 2, 2025

  Based 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. Findings: 1. On 6/30/25 at 11:11 a.m., during a surveyor observation of a medication administration pass, the Certified Nursing Assistant-Medications (CNA-M) left the A wing medication cart in the dining/activity area of the locked Special Care Unit for residents with advanced cognitive impairment. […]

• No harm, potential for more than minimal, patternF880Jul 2, 2025

  Based 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. Finding: On 7/2/25, a surveyor reviewed the facility's Water Management Program to Reduce Legionella Growth and Spread in Buildings policy that was last reviewed by the facility on 10/14/24 and photos of areas where Legionella could grow were updated as needed. The program lacked evidence of measures to prevent the growth of opportunistic waterborne pathogens (also known as control measures), and how to monitor them. […]

• No harm, potential for more than minimal, patternF695Jun 26, 2024

  Based 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). Findings: 1. On 6/24/24 at 9:01 a.m., a surveyor observed that R33's O2 concentrator filter was heavily soiled with dust and debris. On 6/25/24 at 1:17 p.m., a surveyor observed that R33's O2 concentrator filter was heavily soiled with dust and debris, and a trash receptacle containing a plastic trash bag was directly in front of the filter, the plastic trash bag was pulled toward/ against the filter. […]

• No harm, potential for more than minimal, patternF761Jun 26, 2024

  Based 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). Findings: On 6/24/24 at 1:53 p.m., review of the C-D Wing Medication Storage Room revealed on the shelf and available for use: 1 bag containing Prochlorperazine 25 milligram (mg) suppositories with an expiration date of 2/24 1 box Premarin vaginal cream conjugated estrogens 0.625mg/gram with an expiration date of 4/30/24 1 bag containing Acetaminophen Suppositories 650mg with an expiration date of 6/23 In the locked narcotic cabinet, on the shelf and available for use: 1 blister pack of… […]