Caribou Rehab and Nursing Center: Three Falls, Two ER Trips - ME
The incidents happened within roughly two weeks of each other in late October and early November 2025. Federal inspectors cited the facility for causing actual harm to residents, the agency's designation for violations where someone was genuinely hurt, not just placed at risk.
The first resident, identified in inspection records only as R1, was being assisted with a transfer when the aide helping her, CNA1, turned away to throw out a soiled incontinence brief. That moment of inattention was enough. R1 fell. The inspection report describes the injury as major. On October 24, a charge nurse assessed R1 and reached the on-call medical provider, who ordered an emergency room visit for right hip and leg pain.
CNA1 self-reported what had happened to the charge nurse that same day. The Director of Nursing then provided education to both the charge nurse and CNA1 on bed mobility and resident safety. The facility described the incident as isolated.
What the inspection report makes clear is that the care plan for R1 already required extensive assistance and adequate supervision during transfers. The intervention was written down. The aide simply looked away.
Less than two weeks later, on November 3, two more residents were hurt.
R4 was being moved using a Hoyer lift, a mechanical sling device used to transfer residents who cannot bear their own weight. CNA3 failed to spread the lift's feet into the open position before beginning the move. The feet of a Hoyer lift extend outward to create a stable base. Closed, the lift is unstable. The inspection report states that space constraints in the room were a factor, though the report does not elaborate on whether the room had been flagged as unsuitable for Hoyer transfers before that day. R4 slid out of the sling and fell to the ground, experiencing pain. Inspectors noted no lasting injury.
R3's fall happened the same day. CNA4 transported R3 in a wheelchair without attaching the footrests first. R3 fell. Like R1, R3 sustained a major injury and was sent to the emergency room.
In an interview at 4:45 p.m. on November 5, the Director of Nursing and the Administrator confirmed all three incidents to the surveyor, along with the facility's account of what each aide had failed to do.
The corrective actions came quickly once inspectors arrived. The maintenance director went through every wheelchair in the facility and replaced missing or broken footrests. Storage bags were attached to the backs of wheelchairs so footrests would be within reach when a resident didn't need them but a staff member might. R4 was moved to a room equipped with an overhead mechanical lift, eliminating the space problem that CNA3 had cited. Staff completed education on Hoyer transfers, including videos, in-person training, and written tests. Two inservice sessions on resident safety were held on November 5 and 6.
The facility conducted a root cause analysis and presented its corrective actions to the surveyor during the inspection. Inspectors determined the facility was in past non-compliance, meaning the violations had occurred but the facility had taken sufficient steps by the time of the survey to address them.
Three separate aides. Three separate failures. A turned back, a skipped safety step, a missing footrest. None of the mistakes were complicated. All of them were the kind of thing covered in basic training.
R1 went to the emergency room with hip and leg pain. R3 went to the emergency room with major injuries. The inspection report does not say what happened to either of them after that.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Caribou Rehab and Nursing Center from 2025-11-05 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 22, 2026 · Our methodology
Caribou Rehab and Nursing Center in CARIBOU, ME was cited for violations during a health inspection on November 5, 2025.
The incidents happened within roughly two weeks of each other in late October and early November 2025.
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.