Wellspring Lutheran Services

In the surveyor’s words

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

• Actual harm, isolatedF684Aug 14, 2025

  Based on observation, interview and record review, the facility failed to ensure a timely response to a change in condition for Resident #65; assess/respond to abnormal vital signs for Resident #52 and Resident #65; and ensure antibiotics were ordered and administered timely for Resident #63, for three residents (#52, #63 and #65) of four residents reviewed for a change in condition and antibiotic administration, resulting in a delay in treatment, increased abdominal pain and hospitalization for Resident #65, and a delay of antibiotics for Resident #63 with the potential for continued infection and delay in assessment/treatment of abnormal vital signs for Resident #52.Resident #52: A review of Resident #52’s medical record revealed an admission into the facility on [DATE] and date of… […]

• Actual harm, isolatedF689Jan 27, 2023

  This Citation pertains to Intake Numbers MI00119459, MI00119621 and MI00113949. Based on observation, interview, and record review the facility failed to complete post fall assessments for two residents (Resident#1 and Resident #2) and follow care planned interventions for bed mobility for one resident (Resident #4), resulting in Resident #1 and Resident #2 sustaining multiple falls without proper post-fall assessments and interventions. In addition, Resident #4 rolled off the bed during incontinence care and fractured his left hip requiring surgical intervention. The incontinence care was being provided by one Certified Nursing Assistant (CNA), when the care plan dictated a two-person assist. The facility was cited at Past Non-Compliance with a Compliance Date of [DATE]. […]

• No harm, potential for more than minimal, widespreadF921Jul 25, 2024

  Based on observation, interview and record review, the facility failed to 1) Ensure a safe, clean and sanitary environment (Stachybotrys/black-mold and Chaetomium mold), and 2). Maintain and clean the facility kitchen ice machine for resident's, family members, visitors and staff, resulting in the likelihood for respiratory infections, increased bacterial infections, with exposure to molds: damage to nose, throat esophagus, lungs and blood stream, increased antibiotic usage, and unsafe environments. […]

• No harm, potential for more than minimal, widespreadF812Aug 4, 2023

  Based on observation, interview and record review, the facility failed to ensure that the kitchen foods were dated, expired foods disposed of, and documentation of daily cleaning tasks completed per policy, resulting in the potential for cross- contamination and resident illness with the potential for hospitalization for a census of 55 residents. Findings Include: On [DATE] at 1:08 PM, initial tour of the kitchen was begun with Dietary Aide L until Chef Director K arrived. The following expired, undated, and opened foods/containers were observed: Dry Storage Room: Uncooked Rotini Pasta- expired ,d+[DATE] Egg noodles- opened on ,d+[DATE] with no use by date. Bag of Tostitos- not sealed, no open or use by date. 2 large bags of spaghetti - 1 bag opened with no open/use by date. […]

• No harm, potential for more than minimal, patternF578Aug 14, 2025

  Based on interview and record review, the facility failed to ensure Code Status was accurately assessed, documented and accessible in the medical record and plan of care for 4 residents (#9, #27, #28, #45 ) , resulting in the potential for the resident's lack of informed knowledge related to options for code status and miscommunication of code status which could lead to a lack of appropriate interventions for care. Resident #27 (R27) A record review of the Face Sheet and Minimum Data Set/MDS assessment indicated R27 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Unspecified Dementia, severe with other behavioral disturbance, Delusional Disorders, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, and Obstructive and Reflux Uropathy… […]