Wellspring Lutheran Services: Advance Directive Failures - MI
The deficiency, cited under a category covering resident rights, involved the facility's handling of treatment refusal, participation in experimental research, and advance directives. Advance directives are the legal documents, such as living wills and do-not-resuscitate orders, through which residents tell caregivers and family members what should happen to them if they can no longer speak for themselves. When a nursing home fails to properly honor or facilitate those documents, the consequences can reach far beyond a regulatory citation.
Inspectors classified the violation at scope and severity level E, meaning it was not an isolated lapse. It was a pattern. No actual harm was documented, but inspectors determined there was potential for more than minimal harm to residents.
That distinction matters. A pattern means more than one resident was affected, and more than one instance occurred. It means whatever broke down at Wellspring Lutheran Services broke down repeatedly, across enough cases that inspectors couldn't call it a one-time mistake.
The deficiency was one of 11 cited during the August 14 inspection, which was triggered by a complaint.
Advance directive failures tend to surface in nursing homes in a handful of ways. A resident executes a document stating they do not want aggressive resuscitation efforts, and the form is filed away but never makes it into the hands of the staff member on duty when it matters. A resident tells a nurse they want to stop a particular medication or procedure, and the refusal goes undocumented or unheeded. A family member arrives and finds that their loved one, who spent months carefully putting their wishes on paper, received care that contradicted every word of it. The inspection report does not specify which of these failures occurred at Wellspring Lutheran Services, or how many residents were involved. What it confirms is that the problem was not isolated.
The right to refuse treatment and to direct one's own care is not a procedural technicality. For an elderly person living in a nursing facility, often without the ability to advocate loudly for themselves, it may be one of the few forms of control left. A resident who has watched a spouse die after prolonged intervention, and who has made clear they want no part of that for themselves, depends entirely on the facility to carry that wish forward. When the system fails, the resident cannot always catch the failure in time to correct it.
Wellspring Lutheran Services reported a correction date of September 23, 2025, roughly six weeks after the inspection. The facility has not publicly detailed what changes it made.
The inspection that produced this citation was a complaint inspection, meaning someone, a resident, a family member, a staff member, or another party, contacted regulators with concerns before inspectors arrived. Complaint inspections are targeted; inspectors come in already looking for something specific. That eleven deficiencies emerged from a single complaint visit suggests the problems inspectors found extended well beyond whatever originally prompted the call.
Frankenmuth is a small city in Saginaw County, known for its Bavarian-themed tourism. Wellspring Lutheran Services operates within a faith-based network and serves a largely elderly population, as do nearly all long-term care facilities. The residents living there are, by definition, among the most vulnerable to the exact category of failure inspectors documented: people whose ability to direct their own care depends on an institution following through.
A pattern-level violation involving advance directives does not generate the same headlines as a physical abuse finding or a medication overdose. No one bled. No one was hospitalized. The inspection report says so. But the potential the inspectors identified was real, and it pointed toward a category of harm that, when it arrives, often arrives at the worst possible moment, in an emergency, in the middle of the night, when there is no time to sort through paperwork or track down the nurse who knew what the resident wanted.
The facility says it fixed the problem by late September. Whether the residents whose directives were mishandled before that date ever knew their wishes had not been properly honored is not something the inspection report addresses.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 20, 2026 · Our methodology
Wellspring Lutheran Services in Frankenmuth, MI was cited for violations during a health inspection on August 14, 2025.
When a nursing home fails to properly honor or facilitate those documents, the consequences can reach far beyond a regulatory citation.
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.