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Deficiency Records for Wellspring Lutheran Services
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.
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 | 2024-07-25 | 2024-08-28 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-07-25 | 2024-08-28 | 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 | 2024-07-25 | 2024-08-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-07-25 | 2024-08-28 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-07-25 | 2024-08-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-07-25 | 2024-08-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-25 | 2024-08-28 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-07-25 | 2024-08-28 | Y |
| 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 | 2024-07-25 | 2024-08-28 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-07-25 | 2024-08-28 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-07-24 | 2024-08-28 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-07-24 | 2024-08-28 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2024-07-24 | 2024-08-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-07-24 | 2024-08-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-07-24 | 2024-08-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-07-24 | 2024-08-28 | 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 | 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 |
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