Springbrook Center: Care Plan Failures - ME
Federal inspectors found Springbrook Center failed to follow its own care plan for Resident #7, who required full assistance with transfers using a mechanical lift. The resident's care plan specifically called for a medium purple sling, but staff used a large green one instead.
The resident's lift transfer evaluation completed November 4 determined he weighed 195 pounds and required a purple medium sling for use with the electric mechanical lift. The facility updated his care plan and nursing assistant instructions November 7 to reflect this requirement.
Two weeks later, inspectors observed the resident sitting in his wheelchair at 8:50 a.m. with a green large sling underneath his body. Nearly an hour later at 9:28 a.m., the resident remained in the dining room with the same incorrect sling.
The Regional Administrator confirmed to inspectors that the resident was not in the correct sling according to his care plan.
Every nursing assistant interviewed knew exactly how the sling sizing system worked. CNA #5 explained that sling sizes are listed on the iPad system used for documentation and "the sling size goes by color of the edges, for example purple is medium."
CNA #3 said the sling size is listed in the computerized care instructions: "we do it by color. That's how you know what size sling it is by the color on the edges."
CNA #1 confirmed the same system: "the sling size is in the Kardex on the tablet, the edge of the sling is the size by color."
CNA #4 told inspectors she relies entirely on the color coding system. "She doesn't know what the sizes are, she just goes by the color the Kardex says."
CNA #6 provided the most detailed explanation: "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, staff left the resident in the wrong sling throughout the morning inspection period.
The care plan required "dependent assist of 2 for transfers using a mechanical lift with medium (purple) full body sling based on manufacturers guide and nursing assessment." This language appeared in both the formal care plan and the simplified instructions used by certified nursing assistants.
Using an incorrectly sized sling creates safety risks during transfers. A sling that is too large can allow a resident to slip through or shift unexpectedly during lifting. The manufacturer's guidelines and nursing assessment specifically determined the medium purple sling was appropriate for this 195-pound resident.
The resident's quarterly assessment showed he was completely dependent on staff for transfers and required full assistance. This level of dependency makes proper equipment sizing critical for safe transfers.
Federal inspectors cited the facility for failing to implement care plan interventions, finding minimal harm or potential for actual harm to residents. The violation affected few residents but demonstrated a breakdown in following established safety protocols.
The inspection occurred as part of a complaint investigation on October 28, suggesting someone raised concerns about care quality at the facility. The sling sizing violation was among the deficiencies inspectors documented during their review.
Springbrook Center operates at 300 Spring Street in Westbrook. The facility must submit a plan of correction to continue participating in Medicare and Medicaid programs.
The resident remained in the incorrect sling while staff who understood the requirements continued their shifts, leaving the 195-pound man vulnerable during any transfer attempts that might occur.
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.
The resident's care plan specifically called for a medium purple sling, but staff used a large green one instead.
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.