Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Caribou Rehab And Nursing Center during CMS and state inspections, most recent first.
Three residents experienced avoidable falls with two sustaining major injuries due to staff failing to provide required assistance during bed mobility, improper use of a mechanical lift in a cramped room, and omission of wheelchair footrests during transport. These incidents occurred despite care plans and facility policies outlining necessary safety measures.
Staff failed to secure medication and treatment carts, leaving them unlocked and unattended in areas accessible to residents, including those with cognitive impairment. On multiple occasions, carts containing medications, syringes, and other medical supplies were left without proper locking mechanisms, and a resident was observed approaching and touching an unlocked medication cart while staff were not present.
A review of the facility's water management program revealed it lacked documented control measures, monitoring protocols, and testing procedures to prevent the growth and spread of legionella and other water-borne pathogens. This deficiency was confirmed during an interview with maintenance staff.
A staff member was seen pulling a resident backwards in a wheelchair, causing the resident's feet to drag on the floor, and on another occasion, a staff member stood while assisting a resident to eat. Both incidents were confirmed by facility staff and did not uphold resident dignity during transportation and meal assistance.
A resident was observed keeping and self-applying a medicated antifungal powder at bedside without evidence that the IDTM had assessed and determined clinical appropriateness for self-administration, despite a physician's order and an LPN's evaluation.
A resident's advance directive for DNR/DNI was not accurately reflected in the EHR, which incorrectly listed the code status as full code, while the paper record indicated DNR/DNI. This discrepancy was confirmed during a review by a surveyor and the ADON.
A resident developed a new stage III pressure ulcer on the posterior left foot, but the care plan was not updated to reflect this change or the necessary skin care interventions. Review with the ADON confirmed the care plan did not address the resident's current wound status or treatment needs.
A resident did not receive insulin according to the prescribed sliding scale, with staff administering incorrect doses and failing to notify the physician when blood sugar levels exceeded the ordered threshold. Documentation did not show that the physician was contacted or that appropriate orders were obtained.
Surveyors identified multiple instances of improper food storage and handling, including open and undated food items in the freezer, exposed raw meat, expired milk, undated juice containers, and moldy raspberries in the refrigerator. These deficiencies were confirmed by dietary and nursing staff during the survey.
A resident who previously received PCV13 and PPV23 was not offered the updated PCV20 vaccine as recommended by the CDC. Review of clinical records and staff interviews confirmed the absence of documentation or evidence that the updated pneumococcal vaccine was offered.
A resident with dementia, identified as an elopement risk and wearing a wander guard, exited the facility through an unlocked and non-alarmed door. The wander guard did not activate, and the resident remained outside for over thirty minutes before being found by staff after a visitor reported the incident. Staff interviews and video footage confirmed the failure of both door security and monitoring procedures.
Surveyors found that the facility failed to maintain clean oxygen concentrator filters for several residents over a three-day period. Despite a weekly cleaning task assigned to the Charge Nurse, the filters remained heavily soiled with dust and debris. Interviews with staff, including a RN and the DON, confirmed the issue, highlighting a lapse in maintaining respiratory equipment cleanliness.
Expired medications were found in the B Wing Medication Cart and the Medication Storage Rooms for B Wing and C-D Wing. Observations revealed expired Prochlorperazine, Premarin, Acetaminophen, Hydrocodone, Bisacodyl, saline nose spray, and Loratadine, which were available for use despite being past their expiration dates. These findings were confirmed by RNs during the survey.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with urinary Foley catheters. Over several days, surveyors observed that only gloves were used as PPE, with no signage or documentation of EBP. Interviews revealed that staff were unaware of EBP protocols, and residents reported inadequate protective measures during catheter care.
A facility failed to transmit a resident's quarterly MDS to the State MDS database within the required timeframe. The MDS, completed in mid-May, was due by the end of May but was not submitted until late June, 26 days late. The MDS Coordinator was unaware of the delay until informed by a surveyor.
The facility failed to provide annual Infection Control training for a CNA, as required by their program standards. The CNA's last documented training was in December 2022, and the required training for 2023 was not completed until June 2024. This deficiency was confirmed through employee file reviews and staff interviews.
A resident requiring a two-person assist transfer was improperly transferred by a CNA with the help of a non-family member visitor, resulting in a fracture. The CNA was aware of the transfer requirements but proceeded due to the resident's insistence and the absence of another staff member.
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that three residents were free from accident hazards and provided with adequate supervision and assistance devices to prevent accidents, resulting in three avoidable falls, two of which caused major injuries. In one case, a resident with hemiplegia and a history of cerebral infarction required extensive assistance for bed mobility and personal care. During peri-care, a CNA turned away from the resident to dispose of a soiled brief, leaving the resident unattended. The resident, unable to control movement due to hemiplegia, rolled out of bed and sustained a displaced fracture of the right femoral neck and a laceration to the forehead. In another incident, a resident dependent on a mechanical lift (Hoyer) for transfers due to multiple sclerosis was being transferred by two CNAs. The staff failed to open the legs of the Hoyer lift because of space constraints in the resident's room, which was too small to allow proper maneuvering. As a result, the resident slipped out of the sling and fell to the floor, sustaining an abrasion to the upper back. The care plan for this resident specified total dependence on two staff for Hoyer transfers and highlighted the need for adequate space and proper use of equipment. A third resident suffered a fall with major injury during wheelchair transport when a CNA failed to attach footrests to the wheelchair. The resident, who was unable to lift their legs, fell forward from the wheelchair and sustained a nasal bone fracture. Facility policy and posted signage required the use of footrests during all wheelchair transports to prevent injury, but this protocol was not followed, directly leading to the fall.
Unsecured Medication and Treatment Carts Accessible to Residents
Penalty
Summary
Facility staff failed to ensure proper storage and security of medications and medical equipment on multiple occasions. On one occasion, a CNA-M left an unlocked and unattended medication cart in the dining/activity area of a locked Special Care Unit for residents with advanced cognitive impairment. While the CNA-M was administering medications to a resident seated away from the cart, another resident in a wheelchair approached the cart, placed a hand on the lock and a drawer, and then moved away. The CNA-M admitted to not keeping the cart keys with her and confirmed the cart was left unlocked and unattended, a fact also verified by the ADON. On two separate days, a treatment cart containing syringes, lancets, medicated creams, ointments, and powders was observed left unattended and unlocked in a resident hallway. Multiple residents and staff passed by the cart, and the Charge Nurse confirmed the cart did not have a lock. On another occasion, the same type of cart was secured only with a swivel snap hook, not a locking device, and was accessible to residents. The DON acknowledged that the cart required a lock to secure the drawers, and surveyors confirmed the lack of proper security for the treatment cart and its contents.
Deficient Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to fully develop and implement a comprehensive water management program aimed at preventing the growth and spread of legionella and other water-borne pathogens. During a review of the facility's Water Management Program policy and related documentation, it was found that the program did not include evidence of specific control measures to prevent the growth of opportunistic waterborne pathogens, nor did it outline how these measures would be monitored. Additionally, there was no documentation of testing protocols for these control measures, including details on monitoring frequency, acceptable control limits, required interventions if limits were exceeded, or criteria for when water testing for legionella should occur. This deficiency was confirmed during an interview with the facility's maintenance staff.
Failure to Maintain Resident Dignity During Transportation and Meal Services
Penalty
Summary
On one occasion, a staff member was observed pulling a resident backwards in their wheelchair in a hallway, resulting in the resident's feet dragging on the floor. This incident was confirmed by the Assistant Director of Nursing. On a separate occasion during lunch service, a staff member was seen standing while assisting a resident to eat, which was confirmed by Activities staff present at the time. These actions did not maintain the dignity and respect of the residents during transportation and meal services.
Failure to Complete IDTM Assessment for Self-Administration of Medication
Penalty
Summary
The facility's interdisciplinary team meeting (IDTM) group failed to determine if it was clinically appropriate for a resident to self-administer and keep a medicated antifungal powder (Desenex) at bedside. Observation revealed the powder on the resident's nightstand, and the resident reported self-applying the powder as needed. Although there was a physician's order allowing the resident to self-administer the medication and keep it at bedside, and an LPN had evaluated the resident for safe application, there was no evidence that the IDTM had completed the required assessment to determine clinical appropriateness for self-administration, as required by facility policy.
Inaccurate Documentation of Advance Directive in Clinical Record
Penalty
Summary
The facility failed to ensure that a resident's advance directive regarding cardiopulmonary resuscitation (code status) was accurately documented in the clinical record. Upon review, the resident's electronic health record (EHR) listed the code status as FULL CODE, while the paper health record, specifically the hospital discharge summary, indicated DNR/DNI (do not resuscitate/do not intubate). During a joint review of the records by a surveyor and the Assistant Director of Nursing (ADON), it was confirmed that the EHR should have reflected DNR/DNI, not full code. The discrepancy between the electronic and paper records resulted in the resident's wishes regarding resuscitation not being clearly and accurately documented in the EHR.
Failure to Update Care Plan for New Pressure Ulcer
Penalty
Summary
The facility failed to review, revise, and update the care plan for a resident after the discovery of a new stage III pressure ulcer on the posterior of the left foot. Record review showed that the resident's care plan had last been revised for skin alteration on 6/9/25, but there was no evidence that it was updated to address the new pressure ulcer and the associated skin care needs. During an interview, the Assistant Director of Nursing confirmed that the care plan did not reflect the resident's current wound status or the care required for treatment. This deficiency was identified through clinical record review and staff interview, focusing on the lack of timely care plan updates following a significant change in the resident's condition.
Failure to Follow Physician Orders for Sliding Scale Insulin Administration
Penalty
Summary
The facility failed to follow physician orders for the administration of sliding scale insulin for one resident. The resident had a physician order specifying the amount of insulin to be administered based on finger stick blood sugar (FSBS) results, with instructions to call the physician if the FSBS exceeded a certain threshold. On one occasion, the resident's FSBS was recorded as 563, but staff administered 15 units of insulin without contacting the physician as required by the order. On another occasion, the resident's FSBS was 288, but only 3 units of insulin were administered instead of the 6 units specified in the order. These discrepancies were confirmed through record review and interview with the Assistant Director of Nursing. The clinical record did not contain evidence that the physician was notified or that a new order was obtained for insulin administration when the FSBS exceeded the ordered range, and the insulin doses given did not always match the sliding scale instructions.
Improper Food Storage and Handling Practices Observed
Penalty
Summary
Surveyors observed multiple instances of improper food storage, preparation, and service that did not meet professional standards for food safety. On two separate days, the walk-in freezer contained several open and exposed food items, including veggie lasagna, pasta with meat sauce showing freezer burn, pizza with partially peeled plastic wrap, raw Philly chicken slices, and various packages of vegetables and meats that were open and undated. Additionally, in the dayroom refrigerator, there was a half gallon of milk past its expiration date, several open and undated containers of juices, and a pint of raspberries that were shriveled and moldy. These conditions were confirmed by the Dietary Supervisor and a CNA during the survey observations. No information about specific residents or their medical conditions was provided in relation to the deficiency.
Failure to Offer Updated Pneumococcal Vaccination
Penalty
Summary
The facility failed to offer the updated pneumococcal vaccination (PCV20) to one resident, despite CDC recommendations indicating that a dose should be considered at least five years after the last pneumococcal vaccine. Record review showed that the resident had previously received PCV13 in 2015 and PPV23 in 2017, but there was no documentation that the updated vaccine was offered. During interviews, the Assistant Director of Nursing confirmed that there was no evidence of the PCV20 being offered, and the Director of Nursing/Infection Preventionist stated that the facility follows CDC recommendations for pneumococcal vaccinations.
Failure to Monitor Exit Doors and Alarm Systems Resulting in Resident Elopement
Penalty
Summary
A resident with a diagnosis of dementia, identified as an elopement risk and equipped with a wander guard alert device, was able to exit the facility unnoticed. The resident left through an unlocked and non-alarmed door, and the wander guard did not activate an alarm or lock the door as intended. The resident was outside for approximately thirty-three minutes before being found by staff, after a visitor alerted them to the resident's presence outside in a wheelchair near the gazebo across the employee parking lot. Facility records and video surveillance confirmed that the resident exited through the D Wing door without staff awareness. Interviews with staff, including an LPN and the DON, corroborated that the alarm system failed to function and that the door was not secured. The resident was assessed after being returned to the facility and was found to have no lasting effects from the incident. The deficiency resulted from the lack of monitoring and failure of safety devices intended to prevent elopement for residents at risk.
Failure to Maintain Clean Respiratory Equipment
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice by not ensuring that the oxygen concentrator filters for several residents were clean. Over the course of three days, surveyors observed that the oxygen concentrator filters for multiple residents, including Resident #33, Resident #13, Resident #35, Resident #24, and Resident #48, were heavily soiled with dust and debris. These observations were made repeatedly, indicating a persistent issue with the cleanliness of the respiratory equipment. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, confirmed that cleaning the filters on the oxygen concentrators was supposed to be a weekly task assigned to the Charge Nurse. Despite this, the filters remained dusty, as verified by both the surveyor and the Director of Nursing during their observations. This indicates a failure in the facility's process to maintain the respiratory equipment in a clean and safe condition for the residents.
Expired Medications Found in Medication Storage and Cart
Penalty
Summary
The facility failed to ensure that expired medications were removed from the available supply in both the B Wing Medication Cart and the Medication Storage Rooms for B Wing and C-D Wing. During an observation on June 24, 2024, the surveyor found several expired medications in the C-D Wing Medication Storage Room, including Prochlorperazine suppositories, Premarin vaginal cream, Acetaminophen suppositories, and a blister pack of Hydrocodone and Acetaminophen. These medications were available for use despite their expiration dates having passed, with some dating back to February 2024. Further inspection of the B-Wing Medication Storage Room revealed additional expired medications, such as Bisacodyl suppositories, Deep Sea Premium Saline nose spray, Acetaminophen suppositories, Pain Relief Acetaminophen/Aspirin/Diphenhydramine, and Loratadine. The B-Wing Medication Cart also contained a bottle of Loratadine that had expired in December 2023. These findings were confirmed by Registered Nurses present during the observations, indicating a lapse in the facility's medication management protocols.
Inadequate Infection Control for Foley Catheter Care
Penalty
Summary
The facility failed to maintain an effective Infection Control Program, specifically regarding Enhanced Barrier Precautions (EBP) for residents with urinary Foley catheters. Over the course of three days, surveyors observed that there was no personal protective equipment (PPE) other than gloves, nor was there signage notifying of EBP for residents with urinary Foley catheters. This was noted for multiple residents, including Resident #48 and Resident #10. Additionally, there was no documentation available pertaining to the use of EBP, and the Director of Nursing confirmed that the facility did not have a plan in place for the use of EBP for residents with urinary Foley catheters. Interviews with staff and residents further highlighted the deficiency. Resident #48 reported that staff emptied the urinary Foley catheter bag without wearing a protective gown. A registered nurse admitted to not knowing what EBP were and stated that only gloves were worn during urinary Foley catheter care, with sterile equipment used only during insertion. These observations and interviews indicate a lack of adherence to infection control protocols, specifically regarding the use of EBP for residents with urinary Foley catheters.
Delayed Transmission of MDS to State Database
Penalty
Summary
The facility failed to transmit a quarterly Minimum Data Set (MDS) electronically to the State MDS database within the required 14 days of completion for a resident. The quarterly MDS for the resident, with a target date of May 16, 2024, was completed on May 17, 2024. This assessment was supposed to be submitted by May 31, 2024, but was not transmitted until June 26, 2024, resulting in a delay of 26 days. During an interview on June 26, 2024, the MDS Coordinator admitted to just submitting the resident's quarterly MDS and expressed uncertainty about why it was not transmitted earlier. The coordinator was unaware of the transmission failure until questioned by the surveyor.
Deficiency in Annual Infection Control Training for CNA
Penalty
Summary
The facility failed to develop and implement an education program that included annual training on the Infection Control program standards, policies, and procedures for one of the five Certified Nursing Assistants (CNA) reviewed. Specifically, CNA1's employee file and Inservice record showed that the last documented Combined Inservice, which included training on the Infection Control program standards, was completed on December 6, 2022. During an interview with a surveyor, the Clinical Assistant confirmed the absence of evidence that CNA1 completed the required training in December 2023. The Staff Educator later stated that CNA1 completed the Infection Control training on June 25, 2024, but acknowledged that it should have been completed in 2023, which it was not. The surveyor confirmed these findings during the interviews.
Failure to Provide Appropriate Transfer Assistance
Penalty
Summary
The facility failed to ensure that a resident who required a two-person assist transfer received the appropriate assistance. On 4/23/24, a CNA transferred a resident with the help of a non-family member visitor instead of another staff member. The resident, who was identified as needing a two-person assist transfer, later complained of pain in the right knee to right ankle area. An X-ray revealed an acute to subacute non-displaced fracture of the lower tibial shaft, complicated by severe osteoporosis. The CNA admitted to the surveyor that he was aware of the resident's transfer requirements but proceeded with the transfer due to the resident's insistence and the absence of his teammate who was at lunch. Interviews with other staff members, including another CNA and an LPN, confirmed that the resident was indeed a two-person assist transfer. The Physical Therapist also noted that the resident had been evaluated as needing a two-person assist transfer at a previous facility. The incident was reported to the Director of Nursing, and the facility's investigation confirmed the deficiency. The resident was subsequently assessed, and an X-ray was ordered, revealing the fracture. The resident's transfer method was changed to a Hoyer lift following the incident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Caribou
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maine Veterans Home - Caribou | 1.6 mi | — | 5 | 0 |
| Borderview Rehab & Living Ctr | 19.4 mi | — | 0 | 0 |
| Aroostook Health Center | 25.3 mi | — | 22 | 0 |
| Mercy Home | 29.9 mi | — | 0 | 0 |
| High View Rehabilitation And Living Center | 36.2 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.