Deficiency Records for Wellspring Lutheran Nursing and Rehab Services
Updated as of March 01, 2024
A list of the most recent deficiencies for Wellspring Lutheran Nursing and Rehab 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? |
|---|---|---|---|---|
| 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 |
| 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 |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-12-19 | 2024-01-17 | N |
| Develop a communication plan. | Fire Safety | 2023-12-19 | 2024-01-17 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-12-19 | 2024-01-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-19 | 2024-01-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-12-19 | 2024-01-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-12-19 | 2024-01-17 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-12-19 | 2024-01-17 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-12-19 | 2024-01-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-19 | 2024-01-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-12-19 | 2023-12-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-14 | 2023-04-20 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-03-14 | 2023-04-20 | 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 | 2023-03-14 | 2023-04-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-14 | 2023-04-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-14 | 2023-04-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-03-14 | 2023-04-20 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-03-14 | 2023-04-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-14 | 2023-04-20 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-03-14 | 2023-04-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-14 | 2023-04-20 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-02-01 | 2022-03-08 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-02-01 | 2022-03-08 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-02-01 | 2022-03-08 | N |
| Develop a communication plan. | Fire Safety | 2022-02-01 | 2022-03-08 | 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 | 2022-02-01 | 2022-03-08 | 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 | 2022-02-01 | 2022-03-08 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-02-01 | 2022-03-08 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-02-01 | 2022-03-08 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2022-02-01 | 2022-03-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-02-01 | 2022-03-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-01 | 2022-03-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-01 | 2022-03-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-02-01 | 2022-03-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-02-01 | 2022-03-08 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-02-01 | 2022-03-08 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-02-01 | 2022-03-08 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2022-02-01 | 2022-03-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-02-01 | 2022-03-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-01 | 2022-03-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-03 | 2022-03-05 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-02-03 | 2022-03-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-03 | 2022-03-05 | N |
