Springbrook Center: Accident Hazard Harm - ME
The nursing assistant, identified in the inspection report as CNA1, told a surveyor directly what happened in the moments before the fall. Asked whether staff had double-checked the straps before transferring the resident, CNA1 said: "Not that day."
When the registered nurse on duty arrived after the fall, one of the four sling loops was completely detached. "The upper left loop was completely off and hanging on the floor," the RN said. "It was hanging when I first came into the room." The other three loops were still attached. The Hoyer lift itself had no broken parts. The sling had no breaks. EMS used the same sling to move the resident onto a stretcher.
The manufacturer's manual is explicit. Before moving a patient, staff must check that the sling is properly connected to all hooks on the swivel bar. If any attachment is not in place, the patient must be lowered and the problem corrected before proceeding.
Nobody had.
The care plan and the Kardex had also not been updated to reflect that the resident's sling had been changed from green to blue, the director of nursing confirmed in a phone interview with surveyors. CNA1 and a second nursing assistant, CNA2, had both completed Hoyer lift training and passed hands-on competency evaluations within the prior four months.
The lift itself, unit number 8, had passed a facility maintenance inspection on September 30 and an independent contractor inspection in October, weeks before the incident.
Federal inspectors cited the deficiency at the actual harm level.
The resident fell anyway, on a piece of equipment that worked, operated by staff who had been trained, because the one check that would have caught the problem, the 10-second look at four hooks before the patient left the bed, was skipped.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Springbrook Center from 2025-10-28 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: August 4, 2026 · Our methodology
SPRINGBROOK CENTER in WESTBROOK, ME was cited for violations during a health inspection on October 28, 2025.
The nursing assistant, identified in the inspection report as CNA1, told a surveyor directly what happened in the moments before the fall.
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.