Springbrook Center

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observations, record review, and interviews the facility failed to implement the care plan interventions for 1 of 7 residents reviewed for transfers using a mechanical lift. (Resident #7) Findings: Resident #7's Minimum Data Set 3.0, quarterly assessment dated [DATE REDACTED], section GG functional abilities and goals revealed he/she was dependent on staff and required full assistance with transfers. The most recent Lift Transfer evaluation completed on 11/4/25 indicated the residents weight was 195 pounds and required a purple (medium) sling for use with the electric mechanical lift. The care plan and the corresponding Kardex (used by the Certified Nursing Assistant) revised on 11/7/25 include the nursing interventions of 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. On 11/20/25 at 8:50 a.m., observation of Resident #7 in his/her wheelchair with a green (large) sling underneath his/her body. On 11/20/25 at 9:28 a.m., during an interview, Certified Nurses Aid (CNA) #5 stated the slings sizes that are to be used for each resident are on

the iPad (system used for CNA Kardex and documentation) and the sling size goes by color of the edges, for example purple is medium. On 11/20/25 at 9:31 a.m., during an interview, CNA #3, stated 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.

On 11/20/25 at 9:33 a.m., during an interview, CNA #1, stated the sling size is in the Kardex on the tablet,

the edge of the sling is the size by color. On 11/20/25 at 10:24 a.m., during an interview, CNA #4 stated she knows which sling to use by the Kardex and the color is in the Kardex. She doesn't know what the sizes are, she just goes by the color the Kardex says. On 11/20/25 at 10:54 a.m., during an interview, CNA #6, stated she knows what size sling to use by the Kardex. The color of the lining on the outside depicts the size of the sling. The Kardex would say green large or purple medium. On 11/20/25 at 9:49 a.m., both the surveyor and the Regional Administrator observed Resident #7 in the dining room with a green (large) sling under him/her in the wheelchair. At this time, the care plan was reviewed with the Regional Administrator who confirmed Resident #7 was not in the correct sling as per his/her plan of care.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Springbrook Center

300 Spring St Westbrook, ME 04092

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Based on record review and interviews, the facility failed to revise a care plan to reflect the correct size sling used for transfers with a mechanical lift for 1 of 3 residents reviewed for falls with major injury (#1).Findings:On 10/28/25, Resident R1's clinical record was reviewed. The record indicated Resident R1 was admitted to the facility in November, 2020. Diagnoses included: dementia, obesity, lymphedema, dorsalgia, muscle weakness, rheumatoid arthritis, limited mobility, and other morbidities. The Minimum Data Set (MDS) 3.0, Quarterly Assessment, dated 10/17/25, Section GG. Functional Abilities and Goals, revealed Resident R1 was dependent on staff and required full assistance with bed mobility, transfers, and toileting.The care plan and corresponding Kardex (used by Certified Nursing Assistants), revised on 8/5/25, included the intervention to provide Resident R1 with assist of 2 (staff), using a mechanical lift and a green full body sling for all transfers. Review of the Lift-Transfer Evaluation for Resident R1, dated 9/18/25, indicated Resident R1's weight was 239.2 pounds, and the height was 60 inches. The assessment indicated Resident R1 required a blue (extra large) sling for use with the electric mechanical lift. On 10/28/25 at 4:00 p.m., in an interview with a surveyor, CNA2 stated Resident R1 used a blue (extra large) sling.On 10/29/25 at 10:40 a.m., in a telephone interview with the Director of Nursing and Assistant Director of Nursing, a surveyor discussed that Resident R1's care plan and Kardex indicated a green, size large, sling was to be used for transfers, but staff reported a blue sling was used when transferring Resident R1.The Director of Nursing confirmed the care plan and Kardex for Resident R1 had not been updated to reflect the change from a green to a blue sling. The Assistant Director of Nursing stated Resident R1 met the manufacturer's requirements for the blue sling.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Springbrook Center

300 Spring St Westbrook, ME 04092

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

10:40 a.m., in a telephone interview with a surveyor, the DON confirmed the care plan and Kardex had not been updated to reflect the change from a green to a blue sling. During an interview, the surveyor asked what did staff do next before Resident R1 was transferred to the wheelchair? CNA1 stated, We lift (him/her) up and open the legs of the Hoyer. The surveyor asked did staff double check straps before staff moved Resident R1, to make sure everything was safe? CNA1 stated Not that day. On 10/29/25 at 11:30 a.m., in a telephone

interview with a surveyor, the RN on duty at the time of the incident stated I was the one to fill out the incident report and I tried to determine the cause. The first thing I thought was the Hoyer pad must've been broken. On the upper left side of the sling, there was no break on the hooks. The sling was hanging down. I wondered how did he/she fall? I was asking questions of the CNAs and they said he/she jerked and moved and that caused the cradle to change balance. I was trying to check if that would loosen the hook on the cradle. It can open, but there's still some space. I know the upper left (loop) was completely off and hanging

on the floor. It was hanging when I first came into the room. The other 3 (loops) were still attached. The Hoyer pad had no breaks and there were no broken parts of the Hoyer.The EMS (Emergency Medical Services staff) used the same Hoyer pad to lift Resident R1 onto the stretcher.A review of preventive maintenance and safety inspections noted the lift in use at the time of the incident, #8, was inspected by facility maintenance on 9/30/25, and also by an independent contractor in October, 2025. A review of the facility's Safe Resident Handling/Transfer Equipment Policy, dated 3/1/24, stated Staff will complete training and demonstrate competency in the use of safe resident handling equipment. Manufacturers' instructions will be used for all safe resident handling equipment.During an interview with the Administrator stated CNA staff must complete training for use of the mechanical lifts at the time of hire and annually. The training consists of an online module and then hands-on competency training with the rehab department. A review of the training for CNA1 noted training was provided on 7/19/25 and competency was demonstrated at the staff skills fair on 8/6/25. CNA2 was provided training on 7/8/25 and demonstrated competency at the skills fair

on 7/31/25.A review of the manufacturer's operator and maintenance manual, stated in Section Lifting the Patient, page 14, When the sling is elevated a few inches off the surface of the bed and before moving the patient, check again to make sure that the sling is properly connected to the hooks of the swivel bar. If any attachments are not properly in place, lower the patient back onto the stationary surface and correct this problem - otherwise, injury or damage may occur. Adjustments for safety and comfort should be made

before moving the patient.Page 15, Before transferring a patient from a stationary object (wheelchair, commode or bed), slightly raise the patient off the stationary object and check that all sling attachments are secure. If any attachment is not correct, lower the patient and correct the problem, then raise the patient and check again.

Event ID:

Facility ID:

If continuation sheet