Caribou Rehab And Nursing Center

F 0689 Level of Harm - Actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

pedals (footrests) on. I didn't. On 11/5/25 at 4:45 p.m. in an interview the Director of Nursing, and Administrator, a surveyor confirmed that 1) CNA1 turned away from Resident R1 when throwing away a soiled incontinent brief, and in failing to maintain extensive assistance for Resident R1 caused an avoidable fall with major injury. Interventions were in place to include adequate supervision consistent with the resident's needs, goals, and plan of care. 2) CNA3 failed to ensure that the feet of a Hoyer lift were placed in an open position prior to moving Resident R4 due to space constraints in the room, Resident R4 slid out of the Hoyer lift to the ground causing pain to Resident R4, with no lasting injury. 3) CNA4 failed to put footrests on a wheelchair prior to transporting Resident R3 that caused an avoidable fall with major injury. As a result of the facility's investigations of these isolated incidents, the following corrective actions were initiated: On 10/24/25, Resident R1 was assessed by Charge Nurse and an order to send to the emergency room was obtained after speaking to the on call Medical Provider due to right hip/leg pain.On 10/24/25, CNA1 self-reported to the Charge Nurse the circumstances of Resident R1's transfer. Education was provided by the Director of Nursing to the Charge Nurse, and CNA1 regarding bed mobility and safety. Immediate education to Nursing staff on Resident safety with ADL's Immediate education Nursing staff on bed mobility As a result of the facility's investigation the following correction actions were immediately taken on 11/3/25 and 11/4/25 regarding incidents involving Resident R3 and Resident R4 on 11/3/25: On 11/3/25, Resident R3 was assessed and an order to send Resident R3 to the emergency room was obtained by

the Medical Provider. Actions taken by the facility - Immediate education provided to the staff member involved. - Maintenance Director reassessed all wheelchairs and replaced missing or lost foot pedals. Storage bag placed on the back of the wheelchair for foot pedal storage when not in use by the resident by easy access for the employee if assist needed. - Education/Inservice provided on 11/5/25 at 1:30 p.m. and also on 11/6/25 at 3:30 p.m. on Resident safety with ADL's, bed mobility, wheelchair and Hoyer transfers. Resident R4 was immediately moved to a room that has an overhead mechanical lift to allow for adequate space

during transfers. Immediate education on Hoyer transfers. Nursing staff completed education on mechanical lift safety including videos, in person training and tests. At the time of the survey, the facility presented the surveyor with corrective actions taken to address these incidents. The facility was determined to be in past non-compliance after the review and verification of the implemented corrective actions. The facility conducted a root cause analysis and identified factors contributing to falls with injury.

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