Springbrook Center: Accident Hazard Harm - ME
Federal inspectors found the violation at Springbrook Center during a November complaint investigation. The resident's care plan specifically called for a purple medium sling based on a lift transfer evaluation completed November 4. Staff used a green large sling instead.
The resident required full assistance with transfers and depended entirely on staff for mobility, according to quarterly assessment records. A November 4 evaluation determined the resident's 195-pound weight required a medium sling for safe mechanical lift transfers.
The facility's care plan, revised November 7, included explicit nursing interventions: "Provide resident/patient with dependent assist of 2 for transfers using a mechanical lift with medium (purple) full body sling based on manufacturers guide and nursing assessment."
Staff knew the requirements. All six certified nursing assistants interviewed by inspectors explained the color-coding system used to identify sling sizes.
"The sling sizes that are to be used for each resident are on the iPad and the sling size goes by color of the edges, for example purple is medium," CNA #5 told inspectors November 20.
CNA #3 said the same day: "The sling size is on the Kardex and we do it by color. That's how you know what size sling it is by the color on the edges."
Three other nursing assistants gave nearly identical explanations. CNA #1 stated the sling size information was "in the Kardex on the tablet, the edge of the sling is the size by color." CNA #4 said she knew which sling to use "by the Kardex and the color is in the Kardex."
The most detailed explanation came from CNA #6: "The color of the lining on the outside depicts the size of the sling. The Kardex would say green large or purple medium."
Despite this universal understanding of the color-coding system, inspectors observed the resident with the wrong sling twice on November 20.
At 8:50 a.m., the resident sat in a wheelchair with a green large sling underneath. Nearly an hour later, at 9:49 a.m., both the surveyor and the facility's Regional Administrator observed the resident again in the dining room, still with the green large sling under him in the wheelchair.
The Regional Administrator reviewed the care plan on the spot and confirmed the resident was not in the correct sling according to his plan of care.
The violation represents a failure to implement basic care plan interventions designed to ensure safe transfers for dependent residents. Mechanical lift slings must be properly sized to distribute weight correctly and prevent injury during transfers.
Using an oversized sling on a resident can create safety risks during mechanical lift operations. The sling may not provide adequate support or could shift during transfer, potentially causing falls or other injuries.
The facility's own documentation system made compliance straightforward. The Kardex system on staff tablets clearly specified sling sizes by color for each resident. The November 7 care plan revision had been in effect for nearly two weeks when inspectors found the violations.
Staff demonstrated complete knowledge of the color-coding system and the resident's specific requirements. Yet the wrong sling remained in use throughout the inspection day, suggesting either systematic non-compliance with care plans or inadequate supervision of transfer procedures.
The inspection occurred as part of a complaint investigation, though the specific nature of the complaint was not disclosed in available records. The violation affected one of seven residents reviewed for mechanical lift transfer procedures.
Federal regulators classified the deficiency as causing minimal harm or potential for actual harm, affecting few residents. The facility must submit a plan of correction to continue Medicare and Medicaid participation.
The resident remains dependent on staff for all transfers, relying on the mechanical lift system that was not being used according to the individualized care plan designed for his safety.
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: June 20, 2026 · Our methodology
SPRINGBROOK CENTER in WESTBROOK, ME was cited for violations during a health inspection on October 28, 2025.
Federal inspectors found the violation at Springbrook Center during a November complaint investigation.
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.