Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 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.
Code status was not accurately documented or accessible for multiple residents. A resident's Advance Care Planning choices were recorded on assessment forms, but the DNR face sheet, physician orders, and care plans did not reflect the specific CPR, nutrition, hydration, and diagnostic testing preferences. Staff stated the DNR order was obtained from the form and that the details were kept in the chart or binder, but the care plans did not include the residents' code status preferences.
Medication administration errors exceeded the allowed rate when staff mixed chewable ASA with other oral meds and gave it whole to residents instead of chewing it as ordered, and when scheduled meds were delayed or held without provider notification. An RN also gave one resident seven morning meds late and did not inform the MD, while another nurse administered overdue meds to a resident with AFib, HTN, GERD, and AKI after the scheduled time. The facility’s med pass policy required meds to be given within 60 minutes of the scheduled time.
Medication storage was not maintained according to accepted pharmaceutical standards when a med room refrigerator was found at 50 degrees with water accumulation, a wet base, and a floor leak. The refrigerator contained Meropenem IV bulbs prepared for a resident with a PICC line, insulin pens, Engerix-B vaccine, and suppositories, and the suppositories were soaked in clear fluid. The DON said no out-of-range temps had been reported, and the Maintenance Director stated the refrigerator had broken and did not work.
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.
A facility failed to act on a high potassium lab before giving a potassium supplement, failed to assess and treat a resident’s PEG site that showed redness, crusting, and drainage, and failed to follow aseptic practice during midline IV flushing. A nurse administered IV and nasal meds in a hallway, handled the midline without gloves or hand hygiene, and the DON and nurse acknowledged the potassium should have been held and the provider contacted before the dose was given.
A resident with severe cognitive impairment, dementia, and dependence for transfers fell from a wheelchair after an agency CNA, who was using a cell phone nearby, attempted to turn the resident in a tight area near the nurses’ station. Video showed the resident collide with another Geri chair, then be lunged forward out of the wheelchair and fall face first to the floor, while the CNA made only a delayed partial reach and did not immediately render direct care. Records also showed prior wheelchair falls with ED transfers and laceration repairs, and the resident’s care plan identified fall risk and wheelchair safety devices.
Indwelling catheter drainage bag left on floor. A resident with Parkinson’s disease, a stage 4 sacral pressure ulcer, osteomyelitis, neuromuscular bladder dysfunction, and Hospice services was observed in bed with the Foley drainage bag sitting on the floor in a cloth bag rather than hanging freely. The bag was observed on the floor on multiple occasions, and later the tubing urine was very dark with a strong odor in the room. The physician orders and care plan addressed catheter care and securing the tubing, but did not mention keeping the bag off the floor.
Midline Catheter Measurements Not Documented: A resident with a midline catheter for IV ABX had dressing changes documented, but required measurements of external catheter length and arm circumference were not recorded with all dressing changes. The resident’s chart and care plan identified the midline in the RUE, and the DON confirmed the missing measurements and stated they should have been documented in the progress notes.
A facility failed to prevent significant medication errors when an RN delayed and held multiple scheduled meds for one resident, including cardiac and diabetes-related medications, without notifying the MD, and another resident’s overdue morning meds, including Eliquis and Coreg, were also administered late without MD notification. The events involved late med passes, overdue medications on the cart screen, and staff acknowledgment that the physician was not informed.
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.
Code Status Not Accurately Documented or Reflected in Care Plans
Penalty
Summary
The facility failed to ensure code status was accurately assessed, documented, and accessible in the medical record and plan of care for four residents. For each of the residents reviewed, the electronic medical record showed DNR on the face sheet, but the specific choices documented on the Advance Care Planning Form were not reflected in the physician orders or care plans. The report states this created a situation in which the resident's code status preferences were not clearly available in the chart. Resident #27 had diagnoses including unspecified dementia with severe behavioral disturbance, delusional disorders, benign prostatic hyperplasia with lower urinary tract symptoms, and obstructive and reflux uropathy. The Advance Care Planning Form showed No for CPR and Yes for artificial nutrition, artificial hydration, diagnostic testing, and infection control outbreak testing, and the resident signed the form. The electronic record listed DNR on the face sheet, but did not include the resident's specific choices from the form. The DNR order stated no directions specified, the resident advocate consent section was blank, and the order was not up to date with the resident's current status. The care plan did not mention the resident's code status preferences. The medical incapacity determination form indicated the resident was unable to participate in decisions regarding medical or mental health treatment. Resident #9 had diagnoses including history of stroke, right-sided weakness, schizophrenia, dementia, depression, and heart disease, and the MDS indicated severe memory loss; the resident was also receiving hospice services. The Advance Care Planning Form showed No for CPR and artificial nutrition, and Yes for artificial hydration and diagnostic testing, with the guardian's signature. The face sheet listed DNR, but the physician order did not identify the resident's specific choices, and the care plan did not mention code status preferences. Resident #28 had diagnoses including dementia, anxiety, COPD, diabetes, depression, bipolar disorder, hypothyroidism, heart disease, GERD, and gout. The Advance Care Planning Form showed No for CPR and artificial nutrition and Yes for artificial hydration and diagnostic testing, signed by the guardian, but the DNR physician order was written before the guardian signed the form, and the face sheet, physician order, and care plan did not reflect the resident's specific choices. Resident #45 had diagnoses including diabetes, end stage kidney disease with dialysis dependence, depression, heart disease, anxiety, COPD, claustrophobia, and history of stroke. The Advance Care Planning Form showed No for CPR and artificial nutrition and Yes for artificial hydration and diagnostic testing, signed by the resident, but the face sheet, physician order, and care plan did not include the resident's specific code status preferences. During interview, the Social Worker stated that DNR status was not care planned because the policy did not say so, that the physician order and DNR form were uploaded in the chart, and that staff could look up the resident's assessment document or binder for the specific information. The Social Worker also stated that the nurse obtained the physician's DNR order from the code status form and that the specific information was not identified in the care plans.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure medication administration errors remained below 5%, with nine medication errors identified from 25 opportunities during observation of medication passes for three residents, resulting in a 36.0% error rate. During observation, RN K administered chewable aspirin to Resident #57 in a single medication cup with three other oral medications, and the resident swallowed all medications whole rather than chewing the aspirin as ordered. Resident #57 was admitted with diagnoses including osteoporosis, venous insufficiency, and pathological fracture. RN K was also observed administering eight oral medications and one inhaler puff to Resident #1. The resident had diagnoses including chronic systolic congestive heart failure, acute respiratory failure with hypoxia, lobar pneumonia, essential hypertension, and a history of TIA and cerebral infarction. The chewable aspirin ordered for Resident #1 was mixed with the other oral medications in one cup, and the resident swallowed all eight oral pills together without chewing the aspirin as ordered. For Resident #29, seven scheduled morning medications were held without notifying the provider, including medications such as aspirin EC, carvedilol, clopidogrel, Entresto, Jardiance, and vitamin D3. RN K later stated the medications were given late at about 10:30 AM and acknowledged that the physician had not been informed and that the late administration had not yet been documented. The report also described another late medication administration for Resident #58, whose 8:00 AM medications were shown as overdue and were administered at 10:23 AM; Nurse L stated the physician was not called about the delay. The facility policy required medications to be administered within 60 minutes of the scheduled time.
Medication Refrigerator Stored Drugs Outside Required Temperature Range
Penalty
Summary
Medication storage practices were not maintained in accordance with accepted pharmaceutical standards of practice. During inspection of two medication carts and two medication rooms, the refrigerator in the [NAME] Wing Medication Room was found at 50 degrees Fahrenheit, with visible water accumulation on the bottom drawer and a wet base, and the floor had a water leak. Nurse L stated the refrigerator should be maintained at 48 degrees Fahrenheit, and the refrigerator appeared to have been thawing. The contents included two large plastic bags containing a total of nine Meropenem IV solution reconstitution 2GM antibiotic bulbs prepared for a resident receiving antibiotics through a PICC line, as well as insulin pens assigned to residents in the [NAME] Wing, Engerix-B vaccine, and packs of Bisacodyl and Acetaminophen suppositories. The bottom drawer holding the insulin pens and suppositories had water in it, and the two boxes of suppositories were soaked in clear fluid. The DON was informed and stated there were no reports of the temperature being out of range and that all contents would be thrown out, while the Maintenance Director stated the refrigerator had broken and did not work. Facility policy required medication room refrigerators to be maintained at 36 to 46 degrees and temperatures to be recorded twice daily.
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.
Failure to Monitor Abnormal Labs, PEG Site Care, and Midline Flushing
Penalty
Summary
The facility failed to evaluate and contact the provider regarding an abnormal potassium laboratory result before administering potassium chloride to a resident with multiple chronic conditions, including chronic kidney disease, heart failure, atrial fibrillation, and hyperkalemia. The resident’s BMP showed a potassium level of 5.8 mEq/L, which was flagged high, yet the potassium supplement remained ordered and was given on the morning the abnormal result had already been received at the facility. The DON stated the potassium should have been held and the provider contacted before administration, and the nurse stated she had not reviewed the lab results before giving the medication. The facility also failed to provide assessment, monitoring, and treatment for a resident with a PEG tube. The resident had a PEG tube in place, was NPO, and was receiving enteral feeds per the care plan, with diagnoses including dysphagia and gastrostomy status. During observation, the PEG site showed redness, brown crusting, dried blood, and yellowish discharge, and the resident denied that daily treatment or dressing changes had been done. Staff stated there was no treatment order and that the tube was not being used, so the site was not flushed or routinely seen often. In addition, the facility failed to follow standards of practice for midline IV flushing for a resident receiving scheduled IV antibiotics. During medication administration observation, the nurse disconnected the empty antibiotic bulb, flushed the line, and handled the IV cap without gloves and without hand hygiene, while performing the procedure in the hallway in view of others. The same resident also received a nasal spray in the hallway, and the nurse acknowledged forgetting about maintaining privacy by avoiding medication administration in public areas.
Failure to Supervise and Safely Assist a Resident During Wheelchair Transport
Penalty
Summary
The facility failed to provide adequate supervision and safe assistance to prevent falls with injury for one resident who was severely cognitively impaired, dependent in all ADLs and transfers, and receiving hospice services. The resident had diagnoses including end stage renal disease, cardiac defibrillator, anxiety disorder, major depressive disorder, and dementia with behavioral disturbance. The resident was observed in a Geri chair in the hallway near the west hall nursing station, yelling out while staff and visitors passed by, and later was observed in the room with the call light out of reach. Video review of the fall showed the resident self-propelling in a wheelchair near the nursing station while an agency CNA was seated nearby looking at a cell phone and drinking from a water bottle. The resident moved toward another resident seated in a Geri chair, collided with that chair, and continued forward. When the CNA finally approached, she grabbed the wheelchair handles and attempted to turn the resident in a small area with a three-point turn. During the turning motion, the resident’s feet became tucked under the front of the wheelchair and the resident was lunged forward out of the chair and fell face first to the floor. The CNA made only a delayed partial reach as the resident fell and then did not immediately render direct care, instead walking away and looking down the hall before retrieving a vital signs machine. Facility statements and records showed conflicting accounts of the event. The CNA stated she was pushing the resident back to his room and that he leaned forward and fell, while the LPN stated she did not witness the fall and later told the CNA that foot pedals should be used when transporting a person in a wheelchair. The resident had a prior fall from a wheelchair on 7/12/2025 and another on 8/6/2025, both resulting in emergency department transfers and closure with staples or sutures for lacerations. The care plan identified the resident as a fall risk and included use of anti roll back brakes and anti tippers on the wheelchair. The facility’s cell phone and electronic devices guideline stated personal cell phones should not be used in patient care areas or other employees’ work areas.
Indwelling catheter drainage bag left on floor
Penalty
Summary
The facility failed to provide necessary management and care of an indwelling urinary catheter drainage bag for Resident #62 by allowing the bag to sit on the floor instead of hanging freely to drain. On 8/12/2025 at 11:41 AM, the resident was observed lying in bed sleeping with the bed in a very low position and the urinary catheter bag placed in a white cloth bag on the floor, pushed against the floor rather than hanging freely. The resident’s record showed diagnoses including Parkinson’s disease, stage 4 sacral pressure ulcer, osteomyelitis of the vertebra, neuromuscular dysfunction of the bladder, right lower leg contracture, diarrhea, and aphasia, and that the resident was receiving Hospice services. On 8/13/2025 at 10:35 AM and again on 8/14/2025 at 1:10 PM, the urinary catheter bag was still observed on the floor, and on 8/14/2025 there was no dignity bag in place. The urine in the tubing was described as very dark and the room had a very strong odor. The physician orders included catheter care every shift and as needed, with instructions to apply a strap to secure the catheter tubing and ensure a dignity bag was placed on the drainage bag, but the orders did not mention keeping the bag off the floor. The care plan identified the resident as having a 16fr 30cc indwelling Foley catheter for neuromuscular dysfunction of the bladder, but the interventions did not mention keeping the catheter bag off the floor. The IPC Nurse acknowledged that the catheter bag should not have been on the floor and stated she would talk to staff.
Midline Catheter Measurements Not Documented
Penalty
Summary
The facility failed to ensure that assessment measurements for a resident’s midline catheter were completed and documented when the catheter dressing was changed. Resident #29 was admitted with diagnoses including acquired absence of right toe(s), diabetes with foot ulcer, ulcer of the left heel and midfoot, and acute osteomyelitis of the left ankle and foot, and had a midline catheter in the right arm for IV antibiotics. During observation, the resident reported receiving IV antibiotics through the midline catheter, and the dressing covering the insertion site and external catheter did not show the date of the last dressing change. Record review showed the treatment administration record documented dressing changes on 7/24/25, 7/31/25, and 8/7/25, but the documentation for the 7/24/25 and 8/7/25 dressing changes lacked the required external catheter length and arm circumference measurements. The admit/readmit screener also identified the midline in the right upper extremity, and the care plan included measuring the external catheter length on admission, weekly, with each dressing change, and as needed. During interview, the DON stated the measurements should be documented in the progress notes and confirmed the lack of measurements with the dressing changes on 7/24 and 8/7.
Significant Medication Errors With Delayed Administration and No Physician Notification
Penalty
Summary
The facility failed to prevent significant medication errors for two residents during medication administration observations and record review. One resident had diagnoses including Type 2 diabetes mellitus with foot ulcer, cerebral infarction due to occlusion or stenosis of a small artery, atherosclerotic heart disease, and essential hypertension. During the medication pass, the resident asked whether medications could be given after therapy so he would not be tired, and the RN agreed and moved on. Seven scheduled 8:00 AM medications, including Acidophilus, aspirin, carvedilol, clopidogrel, Entresto, Jardiance, and vitamin D3, were then held and later given at about 10:30 AM without notifying the provider of the delay. The RN acknowledged that the medications were administered late and stated that the physician had not been informed. Later the same day, she stated she had not yet had time to notify the physician or document the late administration in the resident’s clinical record. The surveyor noted that the nurse did not explain the consequences of holding the due medications to the resident. The report also states that the medication error calculation was 36% over 25 observations. The following morning, another resident with diagnoses including acute renal failure, UTI, metabolic encephalopathy, paroxysmal atrial fibrillation, essential hypertension, GERD, and atherosclerotic heart disease had seven medications shown as overdue on the medication cart computer screen. The nurse stated that the resident’s medication was not available from the pharmacy and that she was running behind because she had 22 residents with one nurse administering medications. The resident’s 8:00 AM medications, including Eliquis and carvedilol, were administered at 10:23 AM, and the nurse denied calling the doctor for the late administration.
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 | ★★★★★ | 5 | 0 |
| Avista Nursing And Rehabilitation | 8.1 mi | ★★★★★ | 2 | 0 |
| Maple Woods Manor | 9.6 mi | ★★★★★ | 2 | 0 |
| Medilodge Of Montrose Inc | 12.5 mi | ★★★★★ | 28 | 0 |
| Hoyt Nursing & Rehab Centre | 12.9 mi | ★★★★★ | 1 | 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 July 2026) and official state health department websites.