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 25 of 36 citations

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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
No harm, with potential for more than minimal harm
Install an approved automatic sprinkler system.
Widespread (many residents). CMS level F.
Fire safety citation K-0351, Smoke Deficiencies. Inspection of January 14, 2025. Found during a standard inspection.
A waiver was granted (April 30, 2025).
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 January 14, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (February 28, 2025).
No harm, with potential for more than minimal harm
Ensure proper usage of power strips and extension cords.
Widespread (many residents). CMS level F.
Fire safety citation K-0920, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of January 14, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (February 28, 2025).
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 December 20, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (January 17, 2024).
No harm, with potential for more than minimal harm
Develop a communication plan.
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0029, Emergency Preparedness Deficiencies. Inspection of December 20, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (January 17, 2024).
No harm, with potential for more than minimal harm
Install emergency lighting that can last at least 1 1/2 hours.
Widespread (many residents). CMS level F.
Fire safety citation K-0291, Egress Deficiencies. Inspection of December 20, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (January 17, 2024).
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 December 20, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (January 17, 2024).
No harm, with potential for more than minimal harm
Provide a written emergency evacuation plan.
Widespread (many residents). CMS level F.
Fire safety citation K-0711, Miscellaneous Deficiencies. Inspection of December 20, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (January 17, 2024).
No harm, with potential for more than minimal harm
Have restrictions on the use of highly flammable decorations.
Widespread (many residents). CMS level F.
Fire safety citation K-0753, Miscellaneous Deficiencies. Inspection of December 20, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (January 17, 2024).
No harm, with potential for more than minimal harm
Have generator or other power source capable of supplying service within 10 seconds.
Widespread (many residents). CMS level F.
Fire safety citation K-0918, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of December 20, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (January 17, 2024).
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.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0222, Egress Deficiencies. Inspection of January 14, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (February 28, 2025).
No harm, with potential for more than minimal harm
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0223, Egress Deficiencies. Inspection of January 14, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (February 28, 2025).

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.