Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Springbrook Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities who was fully dependent on staff for transfers fell from a mechanical lift during a bed-to-wheelchair transfer when one sling loop was not properly secured to the hanger bar. Two CNAs were present, but the straps were not double-checked before the transfer, and the care plan was not updated to reflect the correct sling size. The resident sustained serious injuries, including fractured ribs, a fractured arm, and a lacerated spleen.
A resident who required full assistance for transfers was observed using a large (green) sling instead of the care-planned medium (purple) sling for mechanical lift transfers. Multiple CNAs relied on the Kardex and sling color coding to select sling size, but the resident was not in the correct sling as specified in the care plan, a fact confirmed by the Regional Administrator.
A resident with multiple comorbidities and full assistance needs had a care plan and Kardex that were not updated to reflect the correct size sling for mechanical lift transfers. Although staff used the appropriate blue (extra large) sling as determined by a transfer evaluation, the documentation continued to specify a green (large) sling, and this discrepancy was confirmed by the DON.
An LPN failed to maintain sterile technique while changing the dressing on a resident's stage 4 pressure ulcer with tunneling by using a piece of silver alginate dressing that had been placed on a non-sterile surface before insertion into the wound, contrary to facility policy and physician's orders.
A CNA-M administered another resident's medications after failing to use two required identifiers, relying instead on room and verbal confirmation. This error resulted in a resident experiencing hypotension and requiring transfer to the ER and subsequent admission to the critical care unit for monitoring and treatment.
The facility failed to maintain a safe, clean, and homelike environment, with deficiencies observed in four units and common areas. Issues included gouged and water-damaged walls, missing laminate, dirt and debris, and stained ceiling tiles. These deficiencies were noted during an environmental tour, highlighting inadequate housekeeping and maintenance services.
The facility failed to update care plans for residents requiring oxygen therapy, leaving them without documented focus, goals, or interventions for their respiratory needs. Additionally, a resident with limited vision and specific ADL requirements was not assisted according to their care plan, resulting in missed meals and lack of toileting support. These deficiencies highlight significant gaps in care planning and implementation.
The facility failed to provide adequate ADL care for two residents, leading to deficiencies in bathing and nutrition. A resident with multiple sclerosis and an amputation received only one shower in June, despite needing weekly assistance. Another resident, requiring help with eating, was observed with uneaten meals while sleeping, with no attempts by staff to assist. These issues were discussed with the facility's management.
A facility failed to manage respiratory care for a resident with COPD, with conflicting oxygen orders and undocumented adjustments. Another resident with a wound on the gluteal folds did not have provider notification or treatment orders. Additionally, a resident who experienced an unwitnessed fall did not receive required neurological assessments, as per facility policy.
A facility failed to ensure staff competency in tracheostomy care for a resident with complex medical needs. A charge nurse, lacking recent training, required coaching during a procedure and relied on others for deep suctioning, despite signing off on the task. The last competency testing was nearly two years prior.
The facility failed to properly store medications, with an unlocked medication cart found unattended and a resident's pills left on an overbed table. A CMT accessed the cart to prepare medication, and a charge nurse confirmed leaving pills unattended for a resident who forgot to take them.
A facility failed to follow a physician's order to refer a resident to a dentist for gingivitis and cleaning. The resident's clinical record showed no evidence of follow-up, and the Marketing Clinical Advisor confirmed that the referral had not been scheduled.
A facility failed to maintain accurate clinical records for a resident's ADL. The resident was observed sleeping through meals without staff cueing and did not eat, yet documentation inaccurately recorded 50% consumption and incorrect levels of assistance. These discrepancies were discussed with the Administrator.
A resident was observed in a common area sitting at a dining table in a wheelchair, naked from the waist down. Two CNAs present did not act to preserve the resident's dignity. An LPN was called to assist in removing the resident to their room. The DON confirmed these findings.
Resident Fall Due to Improper Sling Attachment During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure that sling straps were properly connected to a hanger bar before transferring a resident using an electric mechanical lift, resulting in a resident falling from the lift sling onto the floor and sustaining significant injuries. During the transfer from bed to wheelchair, two CNAs were involved in applying the sling and operating the lift. One CNA moved the lift while the other guided the resident, but the resident rolled out of the sling and fell. Upon assessment, it was found that one of the sling loops had come off the lift hook, and the nurse on duty observed the loop hanging off the swing bar. The resident suffered a contusion, bleeding from the nose, fractured ribs, a fractured left arm, and a lacerated spleen, requiring hospital admission. The resident involved had multiple medical conditions, including dementia, obesity, lymphedema, dorsalgia, muscle weakness, rheumatoid arthritis, and limited mobility, and was fully dependent on staff for mobility and transfers. The care plan specified the use of a green full body sling with two staff for all transfers, but the lift-transfer evaluation indicated a blue (extra large) sling was required. The care plan and Kardex had not been updated to reflect this change. During interviews, staff could not confirm how many times the sling loops were checked before the transfer, and one CNA admitted that the straps were not double-checked on the day of the incident. Review of facility policies and manufacturer instructions revealed that staff are required to check that all sling straps are properly connected to the hanger bar before and after elevating the resident, and to lower the resident if any attachments are not secure. Both CNAs involved had completed required training and demonstrated competency in lift use. The lift and sling were found to be in good working order, with no broken parts, and had passed recent maintenance inspections. Despite these measures, the failure to ensure all sling loops were properly secured directly led to the resident's fall and subsequent injuries.
Failure to Follow Care Plan for Mechanical Lift Transfer Sling Size
Penalty
Summary
The facility failed to implement the care plan interventions for a resident who required transfers using a mechanical lift. According to the resident's most recent assessment and lift transfer evaluation, the resident was dependent on staff for transfers and required the use of a medium (purple) full body sling with the electric mechanical lift. The care plan and CNA Kardex both specified the use of a medium (purple) sling for all transfers, based on the manufacturer's guide and nursing assessment. Despite these documented requirements, observations on the day of the survey found the resident in a wheelchair with a large (green) sling underneath, which did not match the care plan instructions. Multiple CNAs interviewed confirmed that they determine sling size by the color indicated in the Kardex, but the resident was observed using the incorrect color and size. The Regional Administrator also confirmed during the review that the resident was not in the correct sling as per the plan of care.
Failure to Update Care Plan for Correct Sling Size During Transfers
Penalty
Summary
The facility failed to update a resident's care plan and Kardex to accurately reflect the correct size sling required for mechanical lift transfers. The resident, who had diagnoses including dementia, obesity, lymphedema, dorsalgia, muscle weakness, rheumatoid arthritis, and limited mobility, was dependent on staff for all transfers. Although a Lift-Transfer Evaluation determined that the resident required a blue (extra large) sling based on weight and height, the care plan and Kardex continued to instruct staff to use a green (large) sling. Staff interviews confirmed that the blue sling was being used in practice, but the documentation had not been revised to match this change. The DON confirmed that the care plan and Kardex were not updated to reflect the current transfer method.
Sterile Technique Breach During Pressure Ulcer Dressing Change
Penalty
Summary
A deficiency occurred when an LPN failed to maintain sterile technique during a dressing change for a resident with a stage 4 sacrococcygeal pressure ulcer with tunneling. After cleansing the wound, the LPN retrieved a piece of silver alginate dressing that had been resting on the non-sterile outer wrapper of the product packaging and inserted it into the tunneling wound using a sterile cotton-tipped applicator. The LPN acknowledged that the outer surface of the packaging was not sterile and that this action could have contaminated the dressing. Physician's orders required daily cleansing with Vashe solution, drying, and application of silver alginate to the wound bed. Facility policy directed that dressings be opened without contaminating and kept within the open packet or placed directly on top of a barrier.
Failure to Properly Identify Resident Leads to Medication Error and Hospitalization
Penalty
Summary
A medication error occurred when a Certified Nurse's Assistant - Medication Aide (CNA-M) administered medications intended for one resident to another resident. The CNA-M retrieved medication cards from a slot labeled for a specific room and bed, prepared the medications, and asked the resident in that room if they were the name on the medication card. The resident confirmed, and the medications were administered. Upon returning to the medication cart, the CNA-M realized the error and immediately notified the nurse. The CNA-M admitted to not verifying the resident's identity using the required two identifiers, such as the identification bracelet and photograph, as outlined in facility policy. The resident who received the incorrect medications was subsequently assessed and initially found to be stable, but was later transferred to the hospital for abnormal vital signs. The medications administered included several antihypertensive agents and other drugs, which led to a hypotensive episode requiring admission to the critical care unit for monitoring and treatment. Facility policy requires the use of at least two resident identifiers before medication administration, and specifically prohibits using room number or physical location as an identifier. The failure to follow these procedures directly resulted in the medication error and the resident's hospitalization.
Facility Maintenance and Sanitation Deficiencies
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services necessary to maintain the building in good repair and sanitary conditions across four of its seven units, as well as in the clean utility room and the third-floor common area. During an environmental tour, several deficiencies were observed and confirmed. In the Wayside Unit, resident bathrooms had gouged and water-damaged walls with exposed sheetrock, and dirt and debris were found around the toilet base. The Saccarappa Unit had a resident room with a missing piece from the entrance door and an open area under the window sill. The Mayflower Unit had a resident room with peeling laminate and a chipped area on the entrance door, along with stained ceiling tiles in the common area and dirt and debris in the clean utility room. In the King Unit, multiple resident rooms had gouged walls, chipped or gouged doors, and loose or peeling wall cove base in bathrooms. Additionally, the kitchenette counter was missing laminate in several areas.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for residents requiring oxygen therapy and other essential care needs. Specifically, four residents receiving oxygen therapy did not have their care plans updated to include a focus, goal, or intervention related to their oxygen or CPAP therapy. This oversight was identified through observations and reviews of electronic medical records, which showed that orders for oxygen therapy were present but not reflected in the care plans. The lack of proper documentation and planning for these residents' respiratory care needs indicates a significant gap in the facility's care planning process. Additionally, the facility did not implement a care plan for a resident requiring assistance with Activities of Daily Living (ADL), nutrition, and incontinence. The resident, who has limited vision and requires specific assistance during meals, was observed sleeping at the dining table with uneaten meals served on regular plates, contrary to the care plan instructions. The certified nursing assistant (CNA) failed to wake the resident or assist with eating, and repeatedly approached the resident from the left side, which is against the care plan's guidance due to the resident's limited vision. This lack of adherence to the care plan resulted in the resident not receiving the necessary support for eating and toileting over an extended period.
Deficiencies in ADL Care for Bathing and Nutrition
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for two residents, leading to deficiencies in showering/bathing and nutrition. Resident #18, who has multiple sclerosis and an above-the-knee amputation, required extensive assistance for bathing, including a mechanical lift and two-person assistance. However, documentation revealed that Resident #18 received only one shower in June, despite the care plan indicating a need for weekly showers. There was no documentation of any refusal from the resident, and the issue was only addressed after the resident's family intervened. Resident #53, who requires supervision or touching assistance for eating, was observed sleeping at the dining room table with uneaten meals in front of them on multiple occasions. Despite the care plan indicating the need for assistance with eating, the CNA did not attempt to wake or assist the resident during meal times. The resident's guardian expressed concerns about the resident's eating habits and potential hunger-related behaviors. These observations were discussed with the facility's LPN Manager and Administrator, highlighting a failure to provide necessary nutritional support.
Deficiencies in Respiratory Care, Wound Management, and Fall Assessment
Penalty
Summary
The facility failed to properly manage the respiratory care of a resident with Chronic Obstructive Pulmonary Disease (COPD). The resident had conflicting oxygen orders in their clinical record, with one order for 3 liters per minute and another for 2.5 liters per minute. Despite these orders, the resident's oxygen was set at 4 liters per minute, which was not documented or communicated to the provider. The charge nurse confirmed that the resident had been receiving 4 liters for a couple of months, indicating a lack of proper documentation and communication regarding the resident's oxygen needs. In another instance, the facility did not notify the provider or obtain orders for a resident with a wound on the gluteal folds. The wound was identified as moisture-associated skin damage, but there was no documentation of treatment steps taken by the staff. The charge nurse admitted to leaving a message for the skin care team but had not contacted the provider for an order since the wound assessment. This oversight highlights a failure in the facility's process for managing new wounds. Additionally, the facility did not conduct appropriate neurological assessments for a resident who experienced an unwitnessed fall. The resident was found on the floor after losing balance, but there was no evidence of continued neurological monitoring as required by the facility's policy. The Administrator was unable to provide documentation of neurological checks following the fall, indicating a lapse in adherence to the facility's falls management policy.
Inadequate Competency in Tracheostomy Care
Penalty
Summary
The facility failed to ensure that staff maintained the appropriate competency and skill required to provide tracheostomy care for a resident on the Wayside Unit. The deficiency was identified when a surveyor observed a charge nurse performing tracheostomy care for a resident with a tracheostomy, who was dependent on staff for all activities of daily living and had a history of drug-resistant organisms. During the observation, the charge nurse expressed a lack of confidence in performing the procedure and required coaching from the Nurse Practice Educator (NPE) using a check-off sheet. The charge nurse initially did not perform deep suctioning until prompted by the surveyor, despite the resident showing signs of labored breathing and copious secretions. Further investigation revealed that the charge nurse had not received recent training on tracheostomy care, with the last skills fair and competency testing completed nearly two years prior. The charge nurse admitted to relying on other nurses to perform deep suctioning when needed, despite signing off on the treatment administration record as if they had performed the procedure themselves. The facility's assessment indicated that it provides care for respiratory treatments, including tracheostomy care, but the charge nurse's lack of recent training and competency testing contributed to the deficiency.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure proper storage of medications, as observed by surveyors. On the Saccarappa House Unit, an unlocked and unattended medication cart was found in the hallway, which was later accessed by a Certified Medication Technician to prepare a resident's medication. Additionally, on the Wayside Unit, a resident was found asleep in bed with a cup of pills left unattended on the overbed table. The charge nurse confirmed that the pills were left there, as the resident had forgotten to take them.
Failure to Schedule Dental Referral
Penalty
Summary
The facility failed to follow through with a physician's order for a dental referral for a resident. The resident's clinical record included a physician's order dated March 18, 2023, instructing staff to refer the resident to a dentist for gingivitis and a cleaning. However, the clinical record lacked evidence of any follow-up with the dental referral. During an interview with the surveyor on July 17, 2024, the Marketing Clinical Advisor confirmed that the dental referral for the resident had not been scheduled.
Inaccurate Documentation of Resident's Meal Consumption
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurate for a resident reviewed for Activities of Daily Living (ADL). During observations on two separate meal occasions, the resident was seen sleeping through both meals without any cueing from staff and did not consume any food or fluids. However, the certified nursing aid documentation inaccurately recorded that the resident consumed 50% of the meals. Additionally, the documentation incorrectly stated that the resident was under supervision with encouragement or cueing during one meal and was independent with no help or staff oversight during the other meal. These discrepancies were discussed with the Administrator during an interview.
Resident Dignity Not Maintained in Common Area
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect. On April 25, 2024, at 8:20 a.m., a resident was observed in the common area of the Wayside Gardens Unit sitting at the dining table in a wheelchair, naked from the waist down. Two CNAs were present in the dining area serving other residents but did not take any action to address the resident's lack of clothing or preserve the resident's dignity. An LPN, who was nearby passing medications, was called to assist in removing the resident to their room. The Director of Nursing confirmed these findings upon arrival at the unit at 8:30 a.m.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Westbrook
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Barron Center | 1.8 mi | ★★★★★ | 34 | 0 |
| Gorham House | 3.9 mi | ★★★★★ | 15 | 0 |
| Fallbrook Commons | 4.5 mi | ★★★★★ | 0 | 0 |
| Cedars Nursing Care Center | 4.8 mi | ★★★★★ | 1 | 0 |
| Seaside Healthcare Llc | 4.9 mi | ★★★★★ | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.