Clover Health Care: Care Plan Failures Led to Fall - ME
The fall happened on July 19, 2025, at 11:30 in the morning. The resident, identified in inspection records only as Resident #1, had been diagnosed with multiple sclerosis, muscle weakness, and a Stage III pressure ulcer on her sacral region. She had impairment in both legs and one arm. Her care plan, last revised less than a month before the fall, was explicit: two staff members required for any turning or repositioning in bed, two staff members and a mechanical lift required for any transfer between surfaces.
None of that happened.
CNA #1, the float aide assigned to the unit that day, told a state surveyor on August 6 that he had no idea the resident had multiple sclerosis. "I didn't know anything about MS or what it is or that he/she had it," he said. When the surveyor asked whether he had read the resident's care plan or Kardex before providing care, his answer was direct. "I've never looked at one," he said. "I don't think so," he added, specifically about the Kardex. He said he believed only nurses had access to those documents, and that the nurses he worked with all told him different things about how they wanted care delivered.
CNA #3, the regular aide on the unit that day, told surveyors she had informed the float aide that Resident #1 needed two people. "I told him/her to coordinate with me when he/she was ready," she said. She described the resident as someone who required extensive repositioning and experienced significant pain with turning. "He/she has a lot of pain with turning and requires 2 staff to do it appropriately for better positioning," CNA #3 said. She confirmed she had access to care plans and Kardexes.
The coordination never happened.
CNA #1 described what he did instead. He turned the resident onto her right side, positioning her roughly halfway between the side and the middle of the bed, with one knee on top of the other. The resident told him to go get help, and said she was okay holding onto the edge of the air mattress. CNA #1 said he understood she could not move her legs on her own, that she needed staff to move them for her. He left to get a nurse to assist with wound care. He was gone, he said, for only two minutes.
When he returned with the nurse, Resident #1 was on the floor.
She was transferred to the emergency department that same day. The state's Department of Licensing and Certification received notification of the incident the following day, July 20.
Surveyors conducted interviews at the facility over the following weeks. When the administrator sat down with two surveyors on August 5, she acknowledged what the investigation had turned up: staff had not been following care plans. The facility, she said, had taken immediate steps to address the situation after the fall.
What the record shows is a float aide who, by his own account, had never in his time at the facility consulted a care plan or a Kardex for any resident. He learned what he needed to know, he said, by asking other aides. The system he described, one where nurses gave him conflicting instructions and written care guidance was something he assumed he couldn't access, left him walking into a room with a cognitively intact but physically dependent woman and no understanding of what her body could and could not do.
Resident #1 had a BIMS score of 13, meaning she was fully cognitively intact. She knew she needed help. She told the aide to go get it. She held onto the edge of the mattress and waited.
She could not move her legs. She could not reposition herself. She was alone.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Clover Health Care from 2025-08-13 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: November 3, 2026 · Our methodology
CLOVER HEALTH CARE in AUBURN, ME was cited for violations during a health inspection on August 13, 2025.
The fall happened on July 19, 2025, at 11:30 in the morning.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.