Wellspring Lutheran: Critical X-Ray Delay - MI
The resident had received the X-ray at 4:20 PM that same day. Two hours later, the results were faxed to the facility. Yet progress notes show no mention of those results until Wednesday, when the resident was finally transferred to the hospital.
The delay violated the facility's own policy for managing acute changes in resident condition. According to Wellspring's "Change of Condition" policy, staff must "evaluate and manage residents at the facility and avoid transfer to a hospital or emergency room by recognizing an Acute Change of Condition."
The policy defines an acute change as "a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains." It requires licensed nurses to complete assessments and notify physicians of any condition changes, with "continued monitoring and assessment of the resident documented in the resident's clinical record."
But that's not what happened with Resident #65.
The X-ray was completed at 4:20 PM. Results reached the facility by fax at 6:40 PM the same day. Yet nursing staff made no mention of reviewing those results in their documentation until the next day, even as they noted the resident's declining condition.
A facility representative confirmed the timeline during the August inspection. She verified the X-ray completion time and when results were provided to the facility. She acknowledged the results were sent by fax but said she wasn't sure when nurses would have actually received them.
The gap between receiving critical diagnostic results and acting on them raises questions about communication systems at the 725 West Genesee facility. While the X-ray results arrived Tuesday evening, the resident didn't reach the hospital until Wednesday.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" to residents. The deficiency affected "few" residents according to the inspection report.
Wellspring Lutheran Services operates as a nursing facility in Frankenmuth, a small city in Michigan's Saginaw County known for its Bavarian-themed downtown and Bronner's Christmas Wonderland. The facility serves elderly residents requiring skilled nursing care and rehabilitation services.
The inspection was conducted in response to a complaint, though the specific nature of that complaint wasn't detailed in the available documentation. State inspectors reviewed resident records, facility policies, and interviewed staff as part of their investigation.
The X-ray delay represents a breakdown in the clinical communication chain that nursing homes depend on to provide appropriate care. When diagnostic results arrive after regular business hours, facilities must have systems to ensure critical findings reach clinical staff promptly.
Wellspring's policy acknowledges this responsibility, stating that licensed nurses must assess residents and notify physicians based on their findings. The policy emphasizes avoiding unnecessary hospital transfers through proper recognition and management of condition changes.
Yet in this case, the opposite occurred. Rather than prompt recognition and response to diagnostic findings, there was a delay that may have contributed to the resident's eventual hospitalization.
The facility's policy requires documentation of "continued monitoring and assessment" in residents' clinical records. But the inspection found a gap between when X-ray results arrived Tuesday evening and when they were first mentioned in progress notes Wednesday.
That gap coincided with the resident's declining condition, creating a situation where critical diagnostic information sat unreviewed while the person's health deteriorated.
The resident was ultimately transferred to the hospital on Wednesday, a full day after the X-ray results had arrived at the facility. Whether earlier review of those results might have led to different clinical decisions or timing of the hospital transfer remains unclear from the inspection documentation.
Federal inspectors completed their review on August 14, 2025. The facility must submit a plan of correction detailing how it will prevent similar delays in reviewing and acting on critical diagnostic results.
The inspection report notes that anyone seeking information about Wellspring's correction plan should contact either the nursing home directly or the state survey agency responsible for oversight.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wellspring Lutheran Services from 2025-08-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Wellspring Lutheran Services in Frankenmuth, MI was cited for violations during a health inspection on August 14, 2025.
The resident had received the X-ray at 4:20 PM that same day.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.