All citations for Wellspring Lutheran Nursing and Rehab Services

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Wellspring Lutheran Nursing and Rehab Services

Last standard health inspection on record

March 19, 2026

Showing 1 to 15 of 15 citations

  1. No harm, with potential for more than minimal harm

    Develop and maintain an Emergency Preparedness Program (EP).

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0004, Emergency Preparedness Deficiencies. Inspection of March 19, 2026. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 21, 2026).

  2. No harm, with potential for more than minimal harm

    Establish procedures for tracking staff and patients during an emergency.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0018, Emergency Preparedness Deficiencies. Inspection of March 19, 2026. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 21, 2026).

  3. No harm, with potential for more than minimal harm

    Establish policies and procedures for volunteers.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0024, Emergency Preparedness Deficiencies. Inspection of March 19, 2026. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 21, 2026).

  4. No harm, with potential for more than minimal harm

    Establish roles under a Waiver declared by secretary.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0026, Emergency Preparedness Deficiencies. Inspection of March 19, 2026. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 21, 2026).

  5. No harm, with potential for more than minimal harm

    Establish emergency prep training and testing.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0036, Emergency Preparedness Deficiencies. Inspection of March 19, 2026. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 21, 2026).

  6. No harm, with potential for more than minimal harm

    Conduct testing and exercise requirements.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0039, Emergency Preparedness Deficiencies. Inspection of March 19, 2026. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 21, 2026).

  7. No harm, with potential for more than minimal harm

    Provide properly protected cooking facilities.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0324, Smoke Deficiencies. Inspection of March 19, 2026. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 21, 2026).

  8. No harm, with potential for more than minimal harm

    Have approved installation, maintenance and testing program for fire alarm systems.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0345, Smoke Deficiencies. Inspection of March 19, 2026. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 21, 2026).

  9. No harm, with potential for more than minimal harm

    Inspect, test, and maintain automatic sprinkler systems.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0353, Smoke Deficiencies. Inspection of March 19, 2026. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 21, 2026).

  10. No harm, with potential for more than minimal harm

    Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0362, Smoke Deficiencies. Inspection of March 19, 2026. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 21, 2026).

  11. No harm, with potential for more than minimal harm

    Install corridor and hallway doors that block smoke.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0363, Smoke Deficiencies. Inspection of March 19, 2026. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 21, 2026).

  12. No harm, with potential for more than minimal harm

    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0521, Services Deficiencies. Inspection of March 19, 2026. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 21, 2026).

  13. No harm, with potential for more than minimal harm

    Have simulated fire drills held at unexpected times.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0712, Miscellaneous Deficiencies. Inspection of March 19, 2026. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 21, 2026).

  14. No harm, with potential for more than minimal harm

    Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0222, Egress Deficiencies. Inspection of March 19, 2026. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 21, 2026).

  15. No harm, with potential for more than minimal harm

    Have properly installed electrical wiring and gas equipment.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0511, Services Deficiencies. Inspection of March 19, 2026. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 21, 2026).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of October 1, 2026. Inspection results describe the home at the time of each inspection.