Springbrook Center: Care Plan Failures - ME
The incident, investigated during a complaint inspection on October 28, 2025, was rated as causing actual harm.
When a surveyor asked the nursing assistant, identified in the report as CNA1, whether staff had double-checked the sling straps before moving the resident, the answer was direct: "Not that day."
The registered nurse who responded to the fall and filled out the incident report described what she found when she entered the room. The upper left loop of the sling was completely detached and hanging on the floor. The other three loops were still attached to the lift's swivel bar. The sling itself was intact, with no broken parts, and the lift had passed both a facility maintenance inspection on September 30 and an independent contractor inspection in October.
The equipment had not failed. The check had not happened.
The manufacturer's manual, reviewed by inspectors, states explicitly that staff must verify all sling attachments are secure after raising the patient a few inches off the surface, before moving anywhere. If anything is off, the manual says, lower the patient and correct it. The same check is required again before transferring from a wheelchair, commode, or bed.
The nursing assistant's care plan and Kardex had also not been updated to reflect that the resident's sling had been changed from a green to a blue model, the Director of Nursing confirmed in a phone interview with the surveyor.
Both nursing assistants involved had completed Hoyer lift training and demonstrated competency at skills fairs within the previous four months. The training existed. The policy existed. The manual was on file.
When EMS arrived, they used the same sling to lift the resident onto the stretcher.
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, investigated during a complaint inspection on October 28, 2025, was rated as causing actual harm.
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.