Wellspring Lutheran Services
Wellspring Lutheran Services in Frankenmuth, MI — inspection on August 14, 2025.
Found 11 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
nasal spray administered through both his nostrils in the hallway after his PICC Line antibiotic was unhooked.
Nurse K did not wear gloves either when administering the nasal spray.According to R29 EMR reviewed on 8/13/25 at 12:00 PM, it revealed that R29 was admitted to the facility on [DATE]. He was [AGE] years old, admitted with a diagnosis of Type 2 diabetes Mellitus with Foot Ulcer, Non-Pressure chronic Ulcer of the Left Heel and Midfoot with unspecified severity, and osteomyelitis of the left foot and ankle, in addition to other diagnoses. R29 was prescribed the following: Lantus Solostart Subcutaneous Solution Pen-Injector 100 Unit/ML (Insulin Glargine) 10 units, Piperacillin Sodium-Tazobactam Solution Reconstituted 3-0.375 GM q8hours, and Flonase Allergy Relief Nasal Suspension 50 MCG/ACT (Fluticasone Propionate (Nasal) scheduled at 8:00 AM.RN K on 8/13/25 at 8:45 AM indicated that she forgot about maintaining the resident's dignity and privacy by avoiding medication administration in the public areas, such as the hallways and the dining area.A review of the Resident's Rights and Facility's Responsibilities (Undated) Policy was conducted on 8/14/25 at 3:00 PM:Residents RightsThe resident has a right to a dignified existence, self- determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.Dignity, Respect and Quality of LifeA facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.
The facility must protect and promote the rights of the resident.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/14/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Wellspring Lutheran Services
725 West Genesee Frankenmuth, MI 48734
SUMMARY STATEMENT OF DEFICIENCIES
Federal health inspectors cited Wellspring Lutheran Services in Frankenmuth, MI for a deficiency under regulatory tag F-F0578 during a standard health inspection conducted on 2025-08-14.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of Wellspring Lutheran Services.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-23.
Federal health inspectors cited Wellspring Lutheran Services in Frankenmuth, MI for a deficiency under regulatory tag F-F0658 during a standard health inspection conducted on 2025-08-14.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Ensure services provided by the nursing facility meet professional standards of quality.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of Wellspring Lutheran Services.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-23.
the date [DATE] at 4:20 PM that the X-ray was completed for Resident #65.
She also reviewed the time the results were provided to the facility ([DATE] at 6:40 PM).
She said the results were sent to the facility on a fax and she was not sure when the nurses would have received them.
Reviewed the resident's condition was declining and the X-ray results were not mentioned in the progress notes until the next day [DATE] and then the resident was transferred to the hospital.
A review of the facility policy titled, “Change of Condition,” review date [DATE] provided, “Policy: It is the policy of (the facility) to enable staff to evaluate and manage residents at the facility and avoid transfer to a hospital or emergency room by recognizing an Acute Change of Condition and identifying its nature, severity, and causes… An acute change of condition is defined as a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains… The licensed nurse completes an assessment of the resident and based on the findings notifies the physician of any change of condition… Continued monitoring and assessment of the resident is documented in the resident's clinical record.”
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/14/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Wellspring Lutheran Services
725 West Genesee Frankenmuth, MI 48734
SUMMARY STATEMENT OF DEFICIENCIES
Federal health inspectors cited Wellspring Lutheran Services in Frankenmuth, MI for a deficiency under regulatory tag F-F0689 during a standard health inspection conducted on 2025-08-14.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of Wellspring Lutheran Services.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-23.
Federal health inspectors cited Wellspring Lutheran Services in Frankenmuth, MI for a deficiency under regulatory tag F-F0690 during a standard health inspection conducted on 2025-08-14.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of Wellspring Lutheran Services.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-23.
Federal health inspectors cited Wellspring Lutheran Services in Frankenmuth, MI for a deficiency under regulatory tag F-F0694 during a standard health inspection conducted on 2025-08-14.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of Wellspring Lutheran Services.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-23.
Federal health inspectors cited Wellspring Lutheran Services in Frankenmuth, MI for a deficiency under regulatory tag F-F0759 during a standard health inspection conducted on 2025-08-14.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure medication error rates are not 5 percent or greater.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of Wellspring Lutheran Services.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-23.
Federal health inspectors cited Wellspring Lutheran Services in Frankenmuth, MI for a deficiency under regulatory tag F-F0760 during a standard health inspection conducted on 2025-08-14.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure that residents are free from significant medication errors.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of Wellspring Lutheran Services.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-23.
Federal health inspectors cited Wellspring Lutheran Services in Frankenmuth, MI for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2025-08-14.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of Wellspring Lutheran Services.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-23.
According to the 2008 Cross Connection Manual on atmospheric vacuum breakers, AVBs shall not be installed where they will be under continuous pressure for more than 12 hours (i.e. no downstream shutoff valve).
According to the 2008 Cross Connection Manual on chemical feeder backflow prevention, Another concern with a hose being run from a faucet to the dispenser is that many times a valve is installed on the hose downstream of an AVB, which is not allowed since AVBs cannot be subject to continuous pressure.
Facility ID: