CONTACT INFORMATION REVIEWS & MORE DATA
Deficiency Records for Wellspring Lutheran Nursing and Rehab Services
View the most recent health deficiencies and inspection results for Wellspring Lutheran Nursing and Rehab Services. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Wellspring Lutheran Nursing and Rehab Services. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2026-03-19 | 2026-04-21 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2026-03-19 | 2026-04-21 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2026-03-19 | 2026-04-21 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2026-03-19 | 2026-04-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2026-03-19 | 2026-04-21 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2026-03-19 | 2026-04-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2026-03-19 | 2026-04-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2026-03-19 | 2026-04-21 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2026-03-19 | 2026-04-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2026-03-19 | 2026-04-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2026-03-19 | 2026-04-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2026-03-19 | 2026-04-21 | N |
| 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 | 2026-03-19 | 2026-04-21 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2026-03-19 | 2026-04-21 | N |
| Establish emergency prep training and testing. | Fire Safety | 2026-03-19 | 2026-04-21 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2026-03-19 | 2026-04-21 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2026-03-19 | 2026-04-21 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2025-11-21 | 2025-12-01 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2025-01-14 | 2025-04-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2025-01-14 | 2025-02-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2025-01-14 | 2025-02-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2025-01-14 | 2025-02-28 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2025-01-14 | 2025-02-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-01-14 | 2025-02-28 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2025-01-14 | 2025-02-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2025-01-14 | 2025-02-28 | N |
| 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 | 2025-01-14 | 2025-02-28 | 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 | 2025-01-14 | 2025-02-28 | 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 | 2025-01-14 | 2025-02-28 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2025-01-14 | 2025-02-21 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-12-20 | 2024-01-17 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-12-20 | 2024-01-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-20 | 2024-01-17 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-12-20 | 2024-01-17 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-12-20 | 2024-01-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-12-20 | 2024-01-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-12-20 | 2024-01-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-20 | 2024-01-17 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-12-20 | 2024-01-17 | N |
| Develop a communication plan. | Fire Safety | 2023-12-20 | 2024-01-17 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-12-20 | 2024-01-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-12-20 | 2023-12-15 | N |