Wellspring Lutheran Services
Inspection Findings
F-Tag F0550
F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
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 Resident R29 EMR reviewed on 8/13/25 at 12:00 PM, it revealed that Resident R29 was admitted to the facility on [DATE REDACTED]. 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. Resident 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.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wellspring Lutheran Services
725 West Genesee Frankenmuth, MI 48734
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0578
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.
F-Tag F0658
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.
F-Tag F0684
F 0684 Level of Harm - Minimal harm or potential for actual harm
the date [DATE REDACTED] 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 REDACTED] 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 REDACTED] and then the resident was transferred to the hospital.
Residents Affected - Few
A review of the facility policy titled, “Change of Condition,” review date [DATE REDACTED] 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.”
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wellspring Lutheran Services
725 West Genesee Frankenmuth, MI 48734
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0689
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.
F-Tag F0690
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.
F-Tag F0694
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.
F-Tag F0759
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.
F-Tag F0760
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.
F-Tag F0761
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.
F-Tag F0921
F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to ensure the appropriate backflow prevention was installed on cross connections. This deficient practice increases the likelihood of contamination of the water supply due to a backflow event, potentially affecting all residents, staff, and visitors who consume water at the facility. Findings include: On 08/12/2025 at approximately 9:30AM observed a hose with an attached spray nozzle connected to the water line downstream of an atmospheric vacuum breaker (AVB) located in the kitchen near the dishwasher. On 08/12/2025 at approximately 1:30PM during the environmental tour of the facility, an interview was conducted with the Director of Maintenance I on the cross connection related to the attached spray nozzle in the kitchen. The Director of Maintenance I was knowledgeable about the cross connection and removed the hose with the attached spray nozzle. On 08/12/2025 at approximately 1:45 PM observed chemical feed dispenser supplied by the utility sink with an atmospheric vacuum breaker without an attached wasting tee, located in the janitor's closet in the basement, [NAME] hallway, and Morning [NAME] hallway. When interviewed about the cross connection,
the Director of Maintenance I was unfamiliar with wasting [NAME] (or bleeder device). 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.
Event ID:
Facility ID:
If continuation sheet
Wellspring Lutheran Services in Frankenmuth, MI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Frankenmuth, MI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Wellspring Lutheran Services or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.