A list of the most recent deficiencies for Wellspring Lutheran Services. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-08-07 | 2023-11-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-04 | 2023-09-12 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-08-04 | 2023-09-12 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-08-04 | 2023-09-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-04 | 2023-09-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-04 | 2023-09-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-08-07 | 2023-09-12 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-08-07 | 2023-09-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-07 | 2023-09-12 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-08-07 | 2023-09-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-07 | 2023-09-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-27 | 2023-02-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-27 | 2023-01-27 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-04-27 | 2022-05-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-04-27 | 2022-05-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-04-27 | 2022-05-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-27 | 2022-05-23 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-04-26 | 2022-05-23 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-04-26 | 2022-05-23 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-04-26 | 2022-05-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-26 | 2022-05-23 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-04-26 | 2022-05-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-26 | 2022-05-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-04-26 | 2022-05-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-03-03 | 2021-04-01 | Y |
| 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. | Health | 2020-02-05 | 2020-03-12 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-02-05 | 2020-03-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-02-05 | 2020-03-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-02-05 | 2020-03-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-05 | 2020-03-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-02-05 | 2020-03-12 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2020-02-05 | 2020-03-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-02-05 | 2020-03-12 | N |
| 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. | Health | 2020-02-05 | 2020-03-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-05 | 2020-03-12 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2020-02-05 | 2020-03-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-05 | 2020-03-12 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-02-06 | 2020-03-12 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2020-02-06 | 2020-03-12 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-02-06 | 2020-03-12 | N |
| Implement emergency and standby power systems. | Fire Safety | 2020-02-06 | 2020-03-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-02-06 | 2020-03-12 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2020-02-06 | 2020-03-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-02-06 | 2020-03-12 | N |
