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.
The facility did not install appropriate backflow prevention on cross connections, including a hose with a spray nozzle connected downstream of an AVB in the kitchen and chemical feed dispensers lacking wasting tees in janitor's closets. The Director of Maintenance was unfamiliar with certain backflow prevention requirements, leading to noncompliance.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
The facility failed to promptly assess and respond to abnormal vital signs in a resident with cardiac conditions, delayed antibiotic therapy for another resident due to incomplete medication reconciliation at admission, and did not ensure timely completion of a STAT abdominal x-ray or appropriate monitoring for a third resident with post-surgical complications, resulting in delayed treatment and hospital transfer.
The facility was found to have significant deficiencies in maintaining a safe and sanitary environment, including mold in the kitchen ice machine, unsanitary conditions in the Garden View unit, and extensive mold issues in the basement. An independent lab report confirmed the presence of harmful molds, and the facility's boiler licenses were expired. The maintenance director acknowledged ongoing issues with mold and leaking pipes, citing a lack of resources and policy for addressing these problems.
The facility's kitchen was found to have multiple sanitation deficiencies, including unclean equipment, improper food storage, and incomplete cleaning documentation. Observations included a lack of soap and paper towels at a hand sink, food residues on equipment, improperly stored meat, and mold-like substances in the ice machine. The Dietary Manager acknowledged these issues, and the facility lacked a documented cleaning policy for the ice machine.
The facility failed to ensure resident dignity during a physician's visit, where a personal conversation about pain management was overheard by others in the dining room. Additionally, the facility did not respond to call lights promptly and failed to address a resident's grievance, resulting in embarrassment and loss of dignity.
A facility failed to provide a complete Notice of Medicare Non-Coverage and Advanced Beneficiary Notice of Non-Coverage to a resident, leading to a lack of information about appeal rights and potential financial hardships. The resident, who was alert and oriented, continued their stay under private pay after Medicare coverage ended. Staff interviews revealed a misunderstanding about the necessity of issuing the SNF ABN, and the facility's policy was not provided during the survey.
A resident with a history of Alzheimer's and other conditions experienced a fall resulting in a fracture, which was not promptly addressed in her care plan. Despite ongoing complaints of pain and x-ray confirmation of fractures, the facility failed to update the care plan to reflect these changes. The DON acknowledged the oversight, which led to inadequate pain management.
A long-term care facility failed to conduct thorough investigations for injuries of unknown origin for two residents, leading to incomplete investigations and potential recurrence of injuries. One resident with a history of falling was found with skin tears, and the facility did not determine the cause or interview staff. Another resident suffered a fracture not immediately identified, with the facility incorrectly attributing it to an earlier fall. The investigation process was flawed, lacking proper documentation, interviews, and timely reporting.
A resident with a history of stroke, dementia, and multiple sclerosis experienced significant unassessed weight loss due to the facility's failure to provide meals as ordered and notify the physician. The resident's care plan, which included specific dietary preferences like grilled cheese, was not followed, leading to low meal intake and frequent refusals. The staff acknowledged the oversight but did not ensure the resident received the full meal tray. Additionally, there was a lack of communication and documentation regarding the resident's condition, with no notification to the physician or family about the weight loss.
The facility failed to maintain a CPAP machine for a resident with obstructive sleep apnea, as it was not cleaned or bagged according to protocol. Additionally, another resident with COPD and heart disease did not receive oxygen therapy as ordered, with their oxygen tank improperly set and tubing not in use. Both deficiencies highlight lapses in respiratory care and care planning.
A nurse failed to follow proper insulin pen administration procedures for a resident, not waiting the required 5 to 10 seconds after injection before withdrawing the needle, potentially affecting insulin absorption.
The facility failed to secure and label medications on the Garden View unit, with an unlocked treatment cart and un-labeled Hydrocortisone cream. Additionally, the Morning [NAME] unit did not maintain proper temperature logs for medication refrigerators, with missing entries and failure to follow required procedures.
Failure to Ensure Proper Backflow Prevention on Cross Connections
Penalty
Summary
The facility failed to ensure proper backflow prevention on cross connections, as observed during an inspection. A hose with an attached spray nozzle was found connected to a water line downstream of an atmospheric vacuum breaker (AVB) in the kitchen near the dishwasher, which is not compliant with backflow prevention standards. Additionally, chemical feed dispensers supplied by utility sinks with AVBs, but lacking attached wasting tees, were observed in multiple janitor's closets. The Director of Maintenance was knowledgeable about the cross connection in the kitchen but was unfamiliar with the requirement for a wasting tee or bleeder device on the chemical feed dispensers. These deficiencies were identified through observation, interview, and record review.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular residents or events involved.
Failure to Timely Respond to Change in Condition, Abnormal Vitals, and Antibiotic Administration
Penalty
Summary
The facility failed to provide timely and appropriate care in response to changes in condition and abnormal vital signs for multiple residents. For one resident with a history of heart failure, atrial fibrillation, and hyperkalemia, there were repeated instances of abnormal pulse readings documented in the medical record, including bradycardia with heart rates as low as 37 bpm. Despite these abnormal findings, there was no evidence of reassessment, practitioner notification, or follow-up interventions documented. Interviews with the nurse practitioner and DON confirmed that the facility's policy required reassessment and provider notification for out-of-range vital signs, but this was not carried out as required. Another resident, admitted for rehabilitation with diagnoses including cellulitis and UTI, experienced a three-day delay in receiving prescribed antibiotics after transfer from the hospital. The resident reported the delay to staff, and it was discovered that the antibiotic was not ordered because it was missing from the medication list, despite being included in the hospital discharge summary and physician progress notes. The DON and ADON confirmed that the facility's process relied solely on the medication list for new admissions, and did not include review of the discharge summary or progress notes, resulting in the omission and delay of critical antibiotic therapy. A third resident, admitted following hernia surgery and with a history of COPD, experienced a decline in condition characterized by abnormal vital signs, including low blood pressure, high pulse, increased respiratory rate, decreased oxygen saturation, and persistent abdominal pain, nausea, and vomiting. Although a STAT abdominal x-ray was ordered, the order was not processed as STAT, resulting in a delay of over 24 hours before the x-ray was completed and results were communicated. Documentation did not reflect timely assessment or intervention in response to the resident's abnormal vital signs or worsening symptoms, and the resident was ultimately transferred to the hospital after continued decline.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and sanitary environment, as evidenced by the presence of mold and unsanitary conditions in various areas. During an environmental tour, surveyors observed a black mold-like substance on the kitchen ice machine, which had not been cleaned as per the facility's schedule. Additionally, a public bathroom lacked paper towels, and a fan with black dirt on its blades was blowing air toward the nursing station. In the Garden View unit, soiled linens were improperly stored, and a dehumidifier's filter was heavily dust-laden. A small shower room emitted a sewer-like smell due to an open drain. In the basement, significant mold issues were identified, including black mold-like areas on ceiling tiles in the medical records room, therapy storage room, and staff education room. The medical records room also had buckets collecting water from leaking pipes, with visible mold on the ceiling. An independent lab report confirmed the presence of Chaetomium and Stachybotrys molds, which are known to cause respiratory symptoms and other health issues. The facility's maintenance director acknowledged the ongoing issues with mold and leaking pipes, citing a lack of resources and policy for addressing these problems. Furthermore, the facility's boiler licenses were found to be expired, with the maintenance director admitting to giving up on contacting state inspectors. The environmental service manager's job description emphasized the importance of maintaining the building and equipment to protect the safety and health of residents, employees, and visitors, highlighting a failure to meet these essential duties.
Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, which could potentially affect all 53 residents consuming meals prepared there. During an initial tour of the kitchen, several deficiencies were observed. The kitchen hand sink near the ice machine and dish area lacked soap and paper towels, and the Dietary Manager did not replenish these supplies. Equipment such as a large metal can opener and a Robot Coupe food processor were found with food residues, and a heavy-duty blender had dust on it. A large pan of individually wrapped steaks was left at room temperature without any date or time labels, and a white plastic bin containing thickener was also unlabeled. Additionally, a small trash bin was placed on a food prep table next to open food items, and spice containers were sticky and dirty. Further observations revealed that clean dishes were improperly stored while still wet and with food residues. The kitchen ice machine had a black mold-like substance on the seal tape and a dried yellow substance inside, indicating it had not been cleaned as per the facility's schedule. The facility's kitchen cleaning checklists were incomplete, with several areas left blank and undated. The Dietary Manager acknowledged the lack of documentation and the absence of a policy for kitchen ice machine cleaning was noted during the survey.
Failure to Ensure Resident Dignity and Timely Response
Penalty
Summary
The facility failed to uphold the dignity of its residents in several instances. During a physician's visit, a resident was engaged in a personal conversation about their pain management in the main dining room, where other residents and visitors could overhear. This lack of privacy was confirmed by a visitor who expressed discomfort at the personal nature of the discussion being overheard. Additionally, the facility did not respond to call lights in a timely manner, as reported in a Confidential Resident Group Meeting. Furthermore, a grievance from another resident was not addressed, leading to feelings of embarrassment and loss of dignity for the resident involved.
Failure to Provide Complete Beneficiary Notices
Penalty
Summary
The facility failed to provide a complete Notice of Medicare Non-Coverage (NOMNEC) and the Advanced Beneficiary Notice of Non-Coverage (SNF ABN) to a resident, resulting in the resident and/or their representative not being informed of their right to appeal and the potential for undue emotional and financial hardships. The resident, who was alert and oriented, was admitted with Medicare Part B coverage, which ended on February 12, 2024. Although the NOMNEC was issued on February 8, 2024, it was provided too early, and the SNF ABN was not included in the resident's notification file. The resident chose to stay at the facility and pay out-of-pocket after the last covered day, eventually being discharged under private pay insurance status. Interviews with facility staff revealed a misunderstanding regarding the issuance of the SNF ABN. The accounts payable staff, responsible for issuing NOMNEC letters, did not issue the SNF ABN, believing it was unnecessary since the resident opted to go home. The social services manager also did not issue the SNF ABN, as they believed it was not needed due to the resident's decision to discharge themselves. The facility's policy on Beneficiary Notice of Medicare Non-Coverage and the Advanced Beneficiary Notice of Non-Coverage was requested but not provided before the survey exit date.
Failure to Revise Care Plan for Pain Management
Penalty
Summary
The facility failed to review and revise the care plan for a resident who experienced significant changes in her condition, specifically related to pain management. The resident, who was alert and oriented with a BIMS score of 11/15, had a history of Alzheimer's Disease, Dementia, Type 2 Diabetes, and Generalized Anxiety Disorders. She was admitted with these diagnoses and later suffered a fall, resulting in a fracture that was not immediately addressed in her care plan. On June 27, 2024, the resident was observed to be in pain due to a spiral fracture of the right tibia and fibula, which was confirmed by x-ray. Despite the resident's ongoing complaints of pain and the significant findings from the x-ray, the facility did not update her care plan to reflect these changes. The Medication Administration Record showed fluctuating pain levels, but there was no documentation of follow-up or effectiveness of pain interventions. The Director of Nursing admitted that the care plan was not revised to address the resident's severe pain and fractures. The facility's policy required care plans to be reviewed and revised as needs change, but this was not done in a timely manner. The lack of revision in the care plan resulted in the potential for unmet needs and inadequate pain management for the resident.
Inadequate Investigation of Injuries in LTC Facility
Penalty
Summary
The facility failed to conduct thorough investigations for injuries of unknown origin for two residents, resulting in incomplete investigations and the likelihood of injuries reoccurring. Resident #27, who has a history of falling, diabetes, and dementia, was found with two skin tears on her left leg. The facility's investigation was inadequate as it did not determine how the injuries occurred, and there were no interviews or statements from staff who might have witnessed the incident. The Director of Nursing (DON) admitted that the investigation was not thorough, and the facility did not provide additional documentation to explain the cause of the injuries. Resident #11, who has Alzheimer's disease, dementia, and other diagnoses, suffered a fracture that was not immediately identified. After a fall on June 10, 2024, an x-ray showed no fracture, but the resident continued to experience pain. A subsequent x-ray on June 27, 2024, revealed a fracture, but no incident report was created in the electronic medical record. The facility concluded that the fracture was from the original fall, despite evidence suggesting otherwise. The investigation lacked interviews with relevant staff, including those from the rehab department, and did not include a comprehensive review of the resident's care and therapy sessions. The facility's investigation process was flawed, as evidenced by the lack of proper documentation, interviews, and timely reporting. The Assistant Director of Nursing (ADON) conducted interviews informally without collecting written statements or signatures. The investigation summary was incomplete, lacking the author's name, signature, and date of completion. The Administrator and DON acknowledged the deficiencies in the investigation process, admitting that the procedures followed were not acceptable and did not adhere to the facility's policies for investigating and reporting injuries of unknown origin.
Failure to Provide Adequate Nutrition and Notify Physician of Weight Loss
Penalty
Summary
The facility failed to provide adequate nutrition and follow care planned interventions for a resident, resulting in significant unassessed weight loss. The resident, who had a history of stroke, dementia, and multiple sclerosis, required assistance with all activities of daily living and had severely impaired cognition. Observations revealed that the resident's meals were not provided as ordered, with missing main lunch meals and specific dietary requests such as grilled cheese not being fulfilled. The resident's weight had decreased significantly over several months, with no weights recorded for January and February, and there was no documentation that the physician was informed of this weight loss. The dietary staff did not adhere to the resident's care plan, which included providing a regular diet with specific preferences like grilled cheese and cottage cheese. Despite the resident's preference for these items, they were not consistently offered, and the resident's meal intake was low, with frequent refusals noted. The staff, including the server and registered dietician, acknowledged the oversight but failed to ensure the resident received the full meal tray as per the care plan. The server admitted to downsizing portions and not following the meal ticket, while the dietician confirmed that the grilled cheese was on the care plan but not on the meal ticket. Additionally, there was a lack of communication and documentation regarding the resident's condition. The physician was not notified of the significant weight loss, and the family was not informed either. The facility's weight measurement policy required documentation of physician and family notification, but this was not followed. The resident's decreased appetite and meal intake were noted, but appropriate actions to address these issues were not taken, leading to continued weight loss and potential health risks.
Deficiencies in Respiratory Care and Oxygen Therapy
Penalty
Summary
The facility failed to ensure proper maintenance and usage of a CPAP machine for a resident who required it for obstructive sleep apnea. The resident, who was admitted for rehabilitation after hip surgery, had a CPAP machine that was not cleaned or bagged as per the facility's protocol. The resident reported that they had not been offered assistance to clean the CPAP machine, which had not been cleaned for six days, including four days while at the facility. The CPAP care plan was not established until the day of the survey, despite the resident's need for nightly CPAP use. Additionally, the facility did not ensure that another resident received oxygen therapy as ordered. This resident, who had chronic ischemic heart disease, COPD, and Alzheimer's disease, was observed without their oxygen nasal cannula on multiple occasions. The resident's oxygen tank was not set to the prescribed 3 liters per minute, and the resident was found sitting on their oxygen tubing. Despite being reminded of the need for assistance, the resident's oxygen levels were not adequately monitored, and the oxygen care plan was not updated to reflect the current needs.
Improper Insulin Pen Administration
Penalty
Summary
The facility failed to ensure proper insulin pen administration for a resident, leading to the likelihood of decreased insulin absorption and continued misadministration. During a medication administration task, a nurse was observed preparing and administering insulin to a resident. The nurse dialed the insulin pen to the required dose and injected it into the resident's abdomen. However, the nurse did not wait the required 5 to 10 seconds after pushing the plunger before withdrawing the needle, completing the process in only 3 seconds. This action was contrary to the facility's insulin pen administration instructions, which specify holding the pen in the skin for the additional time to ensure the entire dose is dispensed into the subcutaneous tissue.
Medication Security and Temperature Log Deficiencies
Penalty
Summary
The facility failed to ensure proper security and labeling of medications on the Garden View unit. During an observation, the treatment cart was found unlocked with no nurse present, and a tube of Hydrocortisone cream was discovered un-labeled, un-dated, and without a cap. Additionally, nail clippers and scissors were found in the top drawer of the cart. Nurse LPN D, who was in a resident's room at the time, acknowledged the oversight but was unsure how the cart became unlocked. The Director of Nursing (DON) indicated that the second shift nursing staff was responsible for cleaning and dating medications on the carts, but no policy for cleaning medication carts was available. The facility also failed to maintain proper temperature logs for medication refrigerators on the Morning [NAME] unit. Observations revealed that the temperature log for the medication refrigerator had not been documented for the current day, with the last entry being from the previous morning. Another refrigerator's temperature log showed the last check was two days prior. The facility's refrigerator log instructions require exact temperatures to be recorded twice daily, with minimum and maximum temperatures noted once daily, and immediate action to be taken if temperatures are out-of-range. However, these procedures were not followed, as evidenced by the incomplete logs.
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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 Frankenmuth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of Frankenmuth | 0.2 mi | — | 1 | 0 |
| Avista Nursing And Rehabilitation | 8.1 mi | — | 2 | 0 |
| Maple Woods Manor | 9.6 mi | — | 1 | 0 |
| Medilodge Of Montrose Inc | 12.5 mi | — | 25 | 0 |
| Hoyt Nursing & Rehab Centre | 12.9 mi | — | 0 | 0 |
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