Deficiency Records for Wellspring Lutheran Services
Updated as of July 01, 2020
This is not the most recent data for Wellspring Lutheran Services. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| 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 the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-03-14 | 2019-04-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-14 | 2019-04-25 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2019-03-14 | 2019-04-25 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-03-14 | 2019-04-25 | 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 | 2019-03-14 | 2019-04-25 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2019-03-14 | 2019-04-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-14 | 2019-04-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-14 | 2019-04-25 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-03-14 | 2019-04-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-03-14 | 2019-04-25 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-20 | 2019-04-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-03-20 | 2019-04-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-03-20 | 2019-04-16 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2018-10-01 | 2018-10-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2018-03-15 | 2018-05-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-03-19 | 2018-04-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-03-15 | 2018-04-20 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-03-15 | 2018-04-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-03-15 | 2018-04-20 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-03-15 | 2018-04-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-03-15 | 2018-04-20 | N |
| Provide activities to meet all resident's needs. | Health | 2018-03-15 | 2018-04-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-03-15 | 2018-04-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-03-15 | 2018-04-20 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-03-15 | 2018-04-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-03-15 | 2018-04-20 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-03-15 | 2018-04-20 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-03-15 | 2018-04-20 | 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 | 2018-03-15 | 2018-04-20 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2018-03-15 | 2018-04-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-03-15 | 2018-04-20 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2018-03-15 | 2018-04-20 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-03-15 | 2018-04-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2017-12-08 | 2018-01-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-12-08 | 2018-01-15 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2017-12-08 | 2018-01-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2017-12-08 | 2018-01-15 | Y |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2017-07-07 | 2017-10-06 | Y |
| Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. | Health | 2017-07-07 | 2017-10-06 | Y |
| Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. | Health | 2017-07-07 | 2017-09-30 | Y |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2017-07-07 | 2017-09-30 | Y |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2017-07-07 | 2017-09-30 | Y |
| Offer other nutritional food to each resident who will not eat the food served. | Health | 2017-07-07 | 2017-09-30 | Y |
