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, isolatedF689Feb 6, 2025

  Based on interview and record review, the facility failed to develop and implement interventions or revise the fall care plan for one Resident (#1) of three residents reviewed for falls. This deficient practice resulted in R1 falling who sustained a skull fracture with subdural hemorrhage. Findings include: Resident #1 (R1) R1 was admitted to the facility on [DATE]. R1 fell on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. A nurse's progress note dated [DATE] at 11:34 p.m. documented R1 was found by staff on the floor of his room. The progress note indicated R1 was bleeding from a head injury. […]

• No harm, potential for more than minimal, widespreadF921Aug 28, 2025

  Based on observation and interview, the facility failed to maintain plumbing and wastewater lines in good repair. This deficient practice increases the likelihood of contamination of the water supply with potential to affect any or all the residents in the facility. Findings include:On 8/26/2025 at 1:39 PM, observed the ice machine on the resident unit to have the wastewater drain line extending down into the bowl of the outgoing sewer drain line. In an interview with the Maintenance Manager C, he stated he had originally had an air gap present on this ice machine, but the gap was allowing the floor drain to overflow and allowing wastewater to splash from the discharge waste line onto the bottom of the cabinet. […]

• No harm, potential for more than minimal, isolatedF686Jul 10, 2024

  Based on observation, interview, and record review the facility failed to 1) appropriately stage, 2) don personal protective equipment (PPE), 3) consult/involve physician for wound treatment, 4) provide aseptic wound care, 5) perform routine skin assessment, 6) provide accurate wound documentation and 7) implement interventions to prevent the development and worsening of a facility acquired pressure injury for two Residents (#2, #11) out of 2 residents reviewed for pressure ulcers. Findings include: Resident #2 (R2) Review of R2's medical record revealed admission to the facility on [DATE] with diagnoses including multiple sclerosis, diabetes mellitus, dependency on wheelchair, and major depression. […]

• No harm, potential for more than minimal, isolatedF755Jul 10, 2024

  Based on observation, interview, and record review the facility failed to ensure that medication was administered appropriately, reconciled correctly, documented appropriately, and stored appropriately for one Resident (#20) out of 30 residents reviewed for pharmacy services. Findings include: Resident #20 (R20) On 7/9/24 at 9:25 AM, an observation was made of an unattended medication cup with two pills on top of R20's bedside table. R20 was not in her room at this time. This surveyor attempted to get the nurse working on the hall to bring this observation to their attention and conduct an interview, but they were unable to be located. […]

• No harm, potential for more than minimal, isolatedF759Jul 10, 2024

  Based on observation, interview, and record review the facility failed to administer 6 of 32 medications accurately to two residents (#11 and #14) during medication pass, resulting in a medication error rate of 18.75%. Findings include: Resident #14 (R14) During observation of medication administration on 7/9/24 at approximately 7:36 AM, Registered Nurse (RN) D dispensed five medications into medication cups for R14 and took them into R14's room. She proceeded to set them down next to R14's empty breakfast tray, stating she would take the tray and leave the medications. RN D proceeded to walk out and close the resident's door, prior to observing R14 taking her medications. Upon return to the medication cart, an interview was conducted with RN D asking if she often left medication with R14. […]