Springbrook Center: Care Plan Deficiencies - ME
The incident came to light during a complaint inspection completed October 29, 2025. When a surveyor asked CNA1 directly whether staff had double-checked the straps before moving the resident, she said, "Not that day."
The RN who responded to the fall and wrote the incident report described what she found when she entered the room. "The upper left loop was completely off and hanging on the floor. It was hanging when I first came into the room. The other three loops were still attached." She said she initially suspected the sling itself had broken, but it hadn't. The Hoyer lift had passed a facility maintenance inspection on September 30 and an independent contractor inspection in October. Nothing was wrong with the equipment.
The manufacturer's manual is explicit. Before moving a patient, staff are told to check that all sling attachments are secure. If any attachment is not correct, lower the patient and correct the problem before proceeding. The manual states directly: "otherwise, injury or damage may occur."
The care plan and Kardex had not been updated to reflect that the resident's sling had been changed from green to blue, a fact the Director of Nursing confirmed in a telephone interview with the surveyor. Whether that contributed to the failure is unclear from the record. What is clear is that both CNAs involved had completed Hoyer lift training within months of the incident, one as recently as August 6, 2025.
EMS used the same sling to lift the resident onto a stretcher after the fall.
CMS rated the violation at the "actual harm" level.
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 incident came to light during a complaint inspection completed October 29, 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.