Deficiency Records for Wellspring Lutheran Services
Updated as of May 01, 2023
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? |
---|---|---|---|---|
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 |
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 | N |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-03-14 | 2019-04-25 | 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 |
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 |