Wellspring Lutheran Services

Inspectors wroteBased on interview and record review, the facility failed to ensure Code Status was accurately assessed, documented and accessible in the medical record and plan of care for 4 residents (#9, #27, #28, #45 ) , resulting in the potential for the resident's lack of informed knowledge related to options for code status and miscommunication of code status which could lead to a lack of appropriate interventions for care. Resident #27 (R27) A record review of the Face Sheet and Minimum Data Set/MDS assessment indicated R27 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Unspecified Dementia, severe with other behavioral disturbance, Delusional Disorders, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, and Obstructive and Reflux Uropathy in addition to other diagnoses. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication administration error rate of less than 5% when nine (9) medication errors were observed from a total of 25 opportunities for three residents (Resident #1, Resident #29 and Resident # 57) of five (5) residents observed for medication administration, resulting in an error rate of 36.0%. Findings Include: On 8/13/25 at 7:45 AM, Registered Nurse K was observed administering the medication at the [NAME] End Nurse's Station. RN 'K' gave R57 the Chewable Aspirin (ASA) tablet, which was placed with three other oral medications in one medicine cup. R# was observed taking all her medications whole at once and swallowing them after a small cup of water. Resident #57 (R57) A review of R57 Face Sheet revealed R57 was admitted at the facility on 8/9/ 25 with the following diagnoses: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and handle medications in accordance with acceptable pharmaceutical standards of practice and ensure medication refrigerator temperatures outside of acceptable parameters were addressed, resulting in the potential for contamination of medications, a lack of therapeutic benefits necessary to promote healing for residents, increased potential for adverse effects.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the appropriate backflow prevention was installed on cross connections. This deficient practice increases the likelihood of contamination of the water supply due to a backflow event, potentially affecting all residents, staff, and visitors who consume water at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure choices on meals are honored and prompt response to call lights for Resident #6 (R6), maintain the resident's confidentiality of an emergency plan for Resident #49 (R49) and provide resident's privacy during medication administration for Resident #29 (R29) for three residents (R6, R49 and R29) of three reviewed for dignity.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1.) evaluate and contact provider with abnormal laboratory findings prior to medication administration of Potassium supplement for Resident #52; 2.)provide assessment, monitoring, and treatment for a Resident with a PEG (percutaneous endoscopic gastrostomy) tube for Resident #27; and 3.) follow standards of practice for Midline intravenous flushing for Resident #29, of three reviewed for standard of practice. Resident #27 (R27) On [DATE] at 9:00 AM, a record review of the R27's Face Sheet and Minimum Data Set/MDS assessment indicated R27 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a timely response to a change in condition for Resident #65; assess/respond to abnormal vital signs for Resident #52 and Resident #65; and ensure antibiotics were ordered and administered timely for Resident #63, for three residents (#52, #63 and #65) of four residents reviewed for a change in condition and antibiotic administration, resulting in a delay in treatment, increased abdominal pain and hospitalization for Resident #65, and a delay of antibiotics for Resident #63 with the potential for continued infection and delay in assessment/treatment of abnormal vital signs for Resident #52. Resident #52: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate supervision and safely assist residents to prevent falls with injury for one resident (Resident #7) of four residents reviewed for accidents with falls, resulting in R7 falling from their wheelchair, requiring a hospital emergency room visit with laceration repairs.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary management and care of an indwelling urinary catheter drainage bag to ensure it was not sitting on the floor for 1 resident (#62), resulting in the potential for complications including infection, obstruction of urine and a decline in condition. Urinary Catheter Resident #62 On 8/12/2025 at 11:41 AM, Resident #62 was observed lying in bed sleeping. His bed was in a very low position and the urinary catheter bag was in a white cloth bag on the floor; it was not hanging freely to drain and was pushed against the floor. A record review of the Face sheet and electronic medical record indicated Resident #62 was admitted to the facility on [DATE] with diagnoses: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure assessment of measurements for a midline catheter was completed and the midline catheter was flushed appropriately for one Resident #29, of one reviewed for intravenous catheters. A review of Resident #29's medical record revealed an admission into the facility on 7/23/25 with diagnoses that included acquired absence of right toe(s), diabetes with foot ulcer, ulcer of left heel and midfoot, and acute osteomyelitis, left ankle and foot. Further review of the medical record revealed the Resident had a Midline catheter that was used to administer intravenous (IV) antibiotics. On 8/12/25 at 12:45 PM, Resident #29 was observed in their room, laying on the bed. The Resident was interviewed, answered questions and engaged in conversation. The Resident was asked about receiving antibiotics. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to prevent significant medication errors for two (2) resident (Resident #29 and Resident #58) of five (5) residents reviewed for medication errors resulting in potential for serious adverse effects for delayed medication without physician notification of the delay in medication as prescribed and potential for decline or worsening of medical condition. FacilityBased on observation, interview and record review the facility failed to prevent significant medication errors for two (2) resident (Resident #29 and Resident #58) of five (5) residents reviewed for medication errors resulting in potential for serious adverse effects for delayed medication without physician notification of the delay in medication as prescribed and potential for decline or worsening of medical condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) Ensure a safe, clean and sanitary environment (Stachybotrys/black-mold and Chaetomium mold), and 2). Maintain and clean the facility kitchen ice machine for resident's, family members, visitors and staff, resulting in the likelihood for respiratory infections, increased bacterial infections, with exposure to molds: damage to nose, throat esophagus, lungs and blood stream, increased antibiotic usage, and unsafe environments. Findings Include: During the initial facility environmental tour done on [DATE] at 10:00 a.m., the following concerns were observed: -At 10:04 a.m., the kitchen ice machine was found to have a black substance (mold-like) all over the seal tape inside the cover and in the inside back of the machine was observed a dried yellow substance approximately 6 inches near the ice. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a clean and sanitary kitchen and kitchen ice machine, resulting in the likelihood to affect up to 53 residents who currently consumed meals prepared in the facility kitchen, from a census of 53 residents. Findings Include: According to the Michigan Modified Food Code 2012, stated Clean equipment and utensils shall be stored: In a self-draining that allows air drying. All kitchen food prep areas and equipment are to be clean and sanitary. Initial Tour of the Facility Kitchen: On 07/23/24 at 9:46 a.m., a kitchen tour done with Dietary Manager F was done; the following concerns were found: -At 9:47 a.m., the kitchen hand sink closet to the ice machine and dish area was found to not have any soap nor paper towels. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) Ensure dignity during a physician's visit for Resident #10, 2) Respond to call lights timely per a Confidential Resident Group Meeting, and 3) Respond to a grievance from Resident #8, resulting in embarrassment and loss of dignity.

Inspectors wroteBased on interview and record review, the facility failed to provide a complete Notice of Medicare Non-Coverage (NOMNEC) and the Advanced Beneficiary Notice of Non-Coverage (SNF ABN) for one (Resident #300) of three residents reviewed for Beneficiary Notice, resulting in resident and/or a representative not being informed of the right to appeal and the potential for undue emotional and financial hardships.

Inspectors wroteBased on observation, interview, and record review, the facility failed to review and revise care plans with resident changes to ensure that interventions necessary for care services for pain were provided for one resident (Resident #11) of 3 residents reviewed for care plans, resulting in the potential for unmet needs, pain, and suffering.

Inspectors wroteThis Citation pertains to Intake Number MI00145715 Based on observation, interview and record review, the facility failed to do complete investigations for injuries of unknown origin (2 skin tears for Resident #27, fracture for Resident #11) and follow, update, and implement care plan interventions for two residents (Resident #11, Resident #27), resulting in incomplete investigations with the likelihood of the injuries to reoccur.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) Follow care planned interventions; 2) Notify the physician of a significant weight loss; 3) Notify the family of a significant weight loss; and 4) Provide meals as ordered for one resident (Resident #1), resulting in unassessed weight loss, meals not provided as ordered with the likelihood of hunger and continued weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a continuous positive airway pressure machine/CPAP mask was cleaned and bagged after use for 1 resident of 1 resident reviewed (Resident #103) for CPAP's, and ensure that oxygen was on the resident as ordered and update the oxygen care plan for 1 of 2 residents reviewed (Resident #12) for oxygen, resulting in the likelihood of low oxygen, compromised respiratory status, increased lung infection, and increased antibiotic usage for respiratory infection with hospitalization. Findings Include: Resident #103: Review of the Face Sheet, diagnosis list, care plans and physician orders revealed, Resident #103 was [AGE] years old, alert and his own person, admitted to the facility on [DATE] from the hospital for rehab services after hip surgery. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that insulin pen administration was completed per professional standards of practice for one resident (Resident #11) of one resident reviewed for insulin administration, resulting in the likelihood of decreased insulin absorption and continued misadministation.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1). ensure the treatment cart on Garden View unit was locked and secured, 2). ensure 1 tube of medication was labeled, dated and the top was on it, and 3). maintain refrigerator temperature on Morning [NAME] unit, back-up refrigerator, resulting in the likelihood for increased infection rate, increased antibiotic usage, wasted topical medication, and refrigerated medications not usable due to decreased temperature maintenance. Findings Include: Observation of Treatment Cart: During observation done on 7/23/24 at 10:20 a.m., on Garden View unit, the treatment cart was found unlocked and no nurse was in sight. Nurse LPN D was in a resident's room at the time. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the kitchen foods were dated, expired foods disposed of, and documentation of daily cleaning tasks completed per policy, resulting in the potential for cross- contamination and resident illness with the potential for hospitalization for a census of 55 residents. Findings Include: On 8/1/23 at 1:08 PM, initial tour of the kitchen was begun with Dietary Aide L until Chef Director K arrived. The following expired, undated, and opened foods/containers were observed: Dry Storage Room: Uncooked Rotini Pasta- expired 7/25 Egg noodles- opened on 4/25 with no use by date. Bag of Tostitos- not sealed, no open or use by date. 2 large bags of spaghetti - 1 bag opened with no open/use by date. - 1 bag was expired. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents' foods were palatable and served at an appetizing temperature, resulting in, hot food temperature not being maintained upon delivery, temping of hot liquids to ensure the safety of residents and the palatability of food served for Resident #108 and Resident Council Attendees. Findings Include: During initial kitchen tour on 8/1/2023, Chef Director K, was questioned if they temp hot liquids prior to leaving the kitchen/serving to residents and he responded they did not. He was then asked what was an appropriate temperature for hot liquids served to their residents and he was unable to provide an answer. This writer temped the hot water (from the hot water spigot affixed to the brewer) and it was 160 degrees. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a WanderGuard was on and working for one resident (Resident #5), resulting in a lack of assessment of the WanderGuard functionality for numerous shifts and the likelihood of wandering going unnoticed with possible elopement.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely physician visits for one resident (Resident #23), resulting in the missed physician visits, and unassessed health and well-being with the likelihood of health complications going unnoticed.

Inspectors wroteBased on observation, interview and record review, the facility failed to perform hand hygiene and don clean gloves prior to assisting with toileting for one resident (Resident #4); clean and disinfect medical equipment between use for three other residents and the Morning [NAME] hall, resulting in the likelihood of cross-contamination and the spread of infections.