Wellspring Lutheran Services: Dignity Violation - MI
The resident, identified in inspection records only as R29, was 65 years old and had been admitted to the Frankenmuth facility with Type 2 diabetes, a chronic ulcer on his left heel and midfoot, and osteomyelitis, a bone infection, of his left foot and ankle. He was receiving intravenous antibiotics through a PICC line, a catheter threaded into a large vein, along with insulin and a prescription nasal spray.
On the morning of August 13, 2025, at 8:45 AM, a registered nurse identified in the report as Nurse K unhooked R29's PICC line antibiotic and then administered his Flonase nasal spray, spraying it into both nostrils while he stood in the hallway. She did not wear gloves for either task.
When inspectors spoke with her, Nurse K did not dispute what had happened. She said she forgot about maintaining the resident's dignity and privacy by avoiding medication administration in public areas such as hallways and the dining area.
That was the whole explanation. She forgot.
R29's medication regimen at the time included Piperacillin-Tazobactam, an antibiotic given every eight hours through his PICC line to treat the bone infection in his foot, Lantus insulin administered by injection, and Flonase nasal spray scheduled each morning at 8:00 AM. The combination of diagnoses made him a medically complex patient, one receiving the kind of treatment that typically demands careful, controlled conditions.
A PICC line is not a routine IV. It is a long catheter that runs from the arm into a large vein near the heart, used when patients need prolonged antibiotic therapy that cannot be managed with a standard IV. Disconnecting and reconnecting such a line without gloves, in a hallway, creates exposure risks for both the resident and the nurse.
The inspection, completed August 14, 2025, was triggered by a complaint. Inspectors reviewed R29's electronic medical record the day before the inspection concluded and interviewed Nurse K that same morning.
The facility's own policy, reviewed by inspectors during the survey, stated that residents have a right to a dignified existence and that the facility must treat each resident with respect and dignity in a manner and environment that promotes quality of life, recognizing each resident's individuality.
The hallway is not that environment.
CMS rated the violation at the minimal harm level, meaning inspectors determined R29 was not documented as having suffered measurable injury from what occurred. But minimal harm designations describe outcomes, not experiences. R29 was a man with a bone infection in his foot, dependent on intravenous antibiotics, standing in a corridor while a nurse administered his medications in view of whoever happened to be passing through.
The inspection report does not say whether anyone else was present in the hallway. It does not say whether R29 objected or asked to be taken somewhere private. It does not say whether this had happened before.
What it says is that a nurse, when asked, told inspectors she forgot.
Wellspring Lutheran Services is located at 725 West Genesee Street in Frankenmuth, a small city in Saginaw County known largely as a tourist destination. The facility's provider identification number is 235269.
R29 came to Wellspring to be treated for a serious infection eating into the bone of his foot. He was receiving around-the-clock antibiotic therapy through a line that ran to his heart. On a Wednesday morning in August, the nurse responsible for his care brought his medications to him in the hallway and administered them there, without gloves, and later could offer no explanation beyond forgetting.
He was still a patient at the facility when inspectors reviewed his records.
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: August 5, 2026 · Our methodology
Wellspring Lutheran Services in Frankenmuth, MI was cited for violations during a health inspection on August 14, 2025.
He was receiving intravenous antibiotics through a PICC line, a catheter threaded into a large vein, along with insulin and a prescription nasal spray.
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.