Wellspring Lutheran Nursing and Rehab Services

In the surveyor’s words

From the most serious findings on record at Wellspring Lutheran Nursing and Rehab Services, in the surveyor’s own words.

• Actual harm, isolatedF689Feb 3, 2022

  Based on interview and record review the facility failed to ensure adequate assistance during a mechanical lift transfer for one resident (Resident #26) out of three residents reviewed for falls, resulting in a laceration to the back of the head and hospitalization . Findings include: Review of a Mechanical Lift Transfer policy with a revised date of July 2018 revealed, The purpose of this procedure is to assist with lifting or transferring residents using a manual lifting device . Procedure 1. Review the Resident Plan of Care to assess for any special needs of the resident. 2. Gather equipment . 3. […]

• No harm, potential for more than minimal, patternF550Mar 19, 2026

  Based on observation, interview and record review, the facility failed to ensure the highest level of incontinence functioning was maintained for four (R4, R62, R64 and R81) of eight residents reviewed for quality of life, resulting in feelings of embarrassment, humiliation, and degradation.Findings include: As a result of an administrative decision to discontinue brief liners for cost cutting measures, residents (R4, R62 and R64) stated that they are embarrassed to socialize and engage in activities and are experiencing high anxiety due to the lack of incontinence protection the brief inserts provided. […]

• No harm, potential for more than minimal, patternF887Mar 19, 2026

  Based on interview and record review the facility failed to educate and offer Covid-19 vaccination to four residents (R2, R16, R22, and R72) out of five residents reviewed for infection control. This deficient practice resulted in residents being at increased risk for exposure to Covid-19, which may lead to serious illness, complications and potential adverse outcomes.Findings include:R2Record review of electronic medical records (EMR) revealed R2 was admitted to the facility on [DATE] with a pertinent diagnosis of chronic kidney disease. […]

• No harm, potential for more than minimal, isolatedF658Nov 21, 2025

  Based on interview and record review the facility failed to ensure nursing services were provided in accordance with professional standards for one resident (R401) of three residents reviewed for medication administration. This failure had the potential to place R401 at risk for adverse medication effects.Findings include:Findings include:On 10/6/25 at 11:35 AM R401 was interviewed regarding the care the facility provided. R401 said the nurse (later identified as LPN A) had given her a double dose of a medication called Budesonide. R401 said she usually takes two pills but there were four pills in the cup. R401 said when she questioned the nurse, the nurse admitted there should only be two pills. […]

• No harm, potential for more than minimal, isolatedF583Jan 14, 2025

  This citation pertains to intake MI00149175. Based on interview and record review the facility failed to ensure residents privacy was maintained for two residents (R16 and R22) out of 20 residents reviewed for residents' rights. Findings include: Review of a facility reported incident sent to the state agency dated 12/20/24, reported a staff member sent videos to a coworker using Instagram (social media) using private messaging. R16 Review of electronic medical records (EMR) documented R16 was initially admitted into the facility on [DATE] with a pertinent diagnosis of Alzheimer's disease (common cause of Dementia and memory loss). Review of Brief interview for Mental Status (BIMS) dated 10/7/24, R16 scored 3 out of 15 (severe cognitive impairment). […]