Springbrook Center

In the surveyor’s words

From the most serious findings on record at Springbrook Center, in the surveyor’s own words.

• Actual harm, isolatedF689Oct 28, 2025

  Based on record review and interviews, the facility failed to ensure that sling straps were properly connected to a hanger bar before transferring a resident using an electric mechanical lift. This resulted in a resident falling from the lift sling onto floor during the transfer from bed to wheelchair and sustaining fractured ribs, lacerated spleen, and a fractured left arm, for 1 of 3 residents reviewed for falls with major injury (#1).Findings:On 10/27/25, the Division of Licensing and Certification received a report from the facility stating on 10/25/25 a nurse was preparing medications in front of R1's room when he/she heard a loud sound and upon turning around, R1 was found lying face down on the floor. […]

• Actual harm, isolatedF760May 12, 2025

  Based on the complaint intake form, clinical record reviews, interviews, and facility policy, the facility failed to identify the appropriate resident when passing medications resulting the CNA-M admisistering medications to the incorrect resident that resulted in a resident being transported to an Acute Care Emergency Department and later admitted to the hospital critical care unit for monitoring and treatment of low blood pressure. (Resident #1) Findings: The Division of Licensing and Certification received an Adult Protective Services (APS) complaint that indicated on 5/8/25, at 9:20 a.m., Resident #1 received another resident's medications which resulted in a hypotensive episode. […]

• No harm, potential for more than minimal, patternF584Jul 19, 2024

  Based on observations and interview, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and sanitary conditions on 4 of 7 units (Wayside, Mayflower, Saccarappa and King), the clean utility room, the 3rd floor common area for 1 of 1 Environmental tours. Findings: 1. On 7/19/24 from 10:15 a.m. to 10:45 a.m., a surveyor conducted an environmental tour with the Administrator in which the following findings were observed and confirmed: Wayside Unit: -Resident room [ROOM NUMBER] - the bathroom walls were observed to be gouged, and/or water damaged with sheetrock exposed around the toilet. -Resident room [ROOM NUMBER]- The bathroom wall had water damage. […]

• No harm, potential for more than minimal, patternF656Jul 19, 2024

  Based on observations, interviews and record reviews, the facility failed to develop care plans in the area of oxygen therapy for 4 of 5 residents reviewed for respiratory care (#17, #56, #72 and #310). In addition, the facility failed to implement a care plan in the area of Activities of Daily Living (ADL), nutrition and incontinence for 1 of 2 residents reviewed for ADL's (#53). Findings: 1. On 7/15/24 at 9:30 a.m., a surveyor observed oxygen equipment at Resident #17's bedside. A Review of Resident #17's Electronic Medical Record (EMR) found orders dated 4/8/24 for Oxygen therapy and Continuous positive airway pressure (CPAP) therapy. A review of Resident #17's care plan failed to include a focus, goal or intervention in the area of oxygen or CPAP therapy. 2. On 7/15/24 at 9:35 a.m,. […]

• No harm, potential for more than minimal, patternF677Jul 19, 2024

  Based on record reviews, observations and interviews the facility failed to provide Activities of Daily Living (ADL) care in the area of showers/bathing for 1 of 33 residents reviewed (#18), and in the area of nutrition for 1 of 2 sampled residents during 2 of 5 days of survey. (#53). Findings: 1. On 7/15/24 at 11:44 a.m., in an interview with a surveyor, Resident #18 stated a couple weeks ago (she) did not get her weekly shower, due on Sundays, for 2 weeks until her family said something to staff. A review of the clinical record for Resident #18 revealed diagnoses that included multiple sclerosis and an above the knee amputation of the left leg. […]