Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wellspring Lutheran Services during CMS and state inspections, most recent first.
A resident experienced multiple falls, resulting in a skull fracture and subdural hemorrhage, due to the facility's failure to update the fall care plan and implement timely interventions. Despite conducting a medication regimen review and staff education, the facility did not document or implement 30-minute visual checks until days after the injury. The care plan lacked necessary modifications to prevent further falls, contrary to the facility's policies.
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers for two residents. One resident developed a pressure injury that was not properly managed, leading to infection and hospitalization. The facility's documentation and care plan were inadequate, with missing assessments and inconsistent wound care orders. Another resident's wound care involved improper infection control measures, posing a risk of cross-contamination. The facility's policies lacked specific procedures for infection control during wound care.
A facility failed to ensure proper medication administration and storage for a resident. Medications were left unattended on a bedside table, and discrepancies were found in the Medication Administration Record. The resident was not assessed for self-administration, and facility policies were not followed, leading to unsecured medications.
A facility experienced a medication error rate of 18.75% due to a nurse leaving medications unattended with a resident not approved for self-administration and failing to assess another resident's lungs before and after aerosol treatment, violating facility policies.
A resident with hemiplegia attempted to navigate through a congested area near the nurses' station, leading to an altercation with another resident. The incident was not prevented due to inadequate supervision, as staff had left the area unattended. The altercation involved one resident swinging a coffee mug at another, resulting in spilled coffee. The facility's policy on safety interventions, which requires adequate supervision to prevent accidents, was not followed.
Failure to Update Fall Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to develop and implement interventions or revise the fall care plan for a resident who experienced multiple falls, resulting in a significant injury. The resident, who was admitted to the facility, fell multiple times and sustained a skull fracture with subdural hemorrhage after a fall. Despite these incidents, the facility did not update the resident's care plan with new interventions to prevent further falls or injuries. The Director of Nursing (DON) acknowledged that a medication regimen review was conducted after one of the falls, and staff education on fall interventions was completed. However, the DON admitted that 30-minute visual checks were not implemented until several days after the resident's fall that resulted in a skull fracture. The care plan lacked documentation of these interventions, and there was no evidence of care plan modifications following the falls. The facility's policies on fall occurrences and management were not adhered to, as the interdisciplinary team did not review or modify the care plan to minimize repeat falls. The DON expressed disappointment in the facility's fall prevention program, acknowledging a problem with the current system. The facility's failure to update the care plan and implement timely interventions contributed to the resident's repeated falls and subsequent injury.
Deficiencies in Pressure Ulcer Care and Infection Control
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for two residents. For Resident #2, the facility did not appropriately stage the pressure ulcer, failed to don personal protective equipment (PPE) during care, and did not consult or involve a physician for wound treatment. The facility also failed to provide aseptic wound care, perform routine skin assessments, and maintain accurate wound documentation. Resident #2 was admitted with multiple health conditions, including multiple sclerosis and diabetes, and was at risk for pressure ulcer development. Despite having no active pressure ulcers upon admission, Resident #2 developed a pressure injury on the right hip, which was not properly managed, leading to infection and hospitalization. The facility's documentation and care plan for Resident #2 were inadequate, with missing weekly skin assessments and inconsistent wound care orders. The wound care was not effectively coordinated between the facility's wound care nurse, hospice nurse, and physician, resulting in a lack of timely and appropriate interventions. The facility's failure to adhere to its own policies on skin management and pressure ulcer treatment contributed to the worsening of Resident #2's condition. For Resident #11, the facility failed to maintain proper infection control measures during wound care. The wound care nurse did not sanitize the bedside table before placing supplies, touched potentially contaminated surfaces without changing gloves, and did not properly disinfect the area after wound care. These actions posed a risk of cross-contamination and infection. The facility's policies did not include specific procedures for infection control during wound care, leading to lapses in practice.
Medication Administration and Storage Deficiency
Penalty
Summary
The facility failed to ensure proper medication administration, reconciliation, documentation, and storage for a resident. An unattended medication cup with two pills was found on the resident's bedside table, and the resident was not present in the room. The medications were identified as trazadone and cyclobenzaprine, with trazadone ordered for evening administration and cyclobenzaprine as needed. The Medication Administration Record (MAR) showed discrepancies in the administration of cyclobenzaprine, which was last recorded as given two days prior. The resident's care plan and physician orders did not include self-administration of medications, and there was no documentation of medication reconciliation for cyclobenzaprine. The incident was traced back to an LPN who had dispensed the medications the previous evening. The LPN left the medications unattended on the resident's bedside table after being called away to assist another resident. The facility's policies on self-administration and medication pass guidelines were not followed, as the resident was not assessed for self-administration, and medications were left unattended. The failure to adhere to these policies resulted in the medications being left in an unsecured manner, posing a potential risk to the resident and others.
Medication Administration Errors and Policy Non-Compliance
Penalty
Summary
The facility failed to administer medications accurately, resulting in a medication error rate of 18.75%. During a medication pass, a registered nurse (RN) dispensed five medications for a resident and left them unattended in the resident's room without observing the resident taking them. This was against the facility's Medication Pass Guidelines, which require observing the resident swallow oral drugs unless the resident is approved for self-administration. The resident confirmed that this was a daily occurrence, and the Director of Nursing verified that the resident was not approved for self-administration. Additionally, the same RN failed to properly assess another resident before and after administering aerosol medication. The RN did not use a stethoscope to assess the resident's lungs, which is required by the facility's Nebulizer Therapy policy. The policy mandates assessing therapy efficacy by monitoring breath sounds and observing for adverse reactions. The RN acknowledged the oversight during an interview, confirming the failure to adhere to the established procedures.
Inadequate Supervision Leads to Resident Altercation
Penalty
Summary
The facility failed to provide adequate supervision to prevent an altercation between two residents, identified as R1 and R2. The incident occurred when R1 attempted to navigate through a congested area near the nurses' station, which was blocked by wheelchairs. R1, who uses a wheelchair for mobility due to hemiplegia, tried to move past R2, who was also in a wheelchair. R2 grabbed R1's arm, prompting R1 to swing a coffee mug at R2 multiple times, resulting in coffee being spilled on R2's face and shirt. The altercation was observed by a certified nurse aide (CNA E) and was later confirmed through a review of camera footage by the Nursing Home Administrator and a social worker. The footage showed that the area around the nurses' station was congested with residents in wheelchairs and chairs, and staff had left the area unattended just before the incident. Despite the presence of three staff members in the area prior to the altercation, none were supervising the residents at the time of the incident. Interviews with staff, including the Nursing Home Administrator and RN D, revealed that the congestion was due to residents being moved to the dining room for dinner. The Nursing Home Administrator acknowledged that the staff should have been supervising the residents and been aware of the congestion. The facility's policy on safety interventions emphasizes the need for adequate supervision to prevent accidents, which was not adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fairview
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Villa At Rose City | 21.1 mi | — | 0 | 0 |
| Medilodge Of Hillman | 25 mi | — | 29 | 0 |
| Mission Point Nursing & Physical Rehabilitation Of | 29.8 mi | — | 9 | 0 |
| Lincoln Haven Nursing & Rehabilitation Community | 31.8 mi | — | 13 | 0 |
| The Villa At West Branch | 32.5 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.