All citations for Wellspring Lutheran 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.

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Last standard health inspection on record

August 28, 2025

Showing 1 to 14 of 14 citations

  1. Harm to a resident

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

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

    Health citation F-0689, Quality of Life and Care Deficiencies. Inspection of February 6, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (March 12, 2025).

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

    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

    Widespread (many residents). CMS level F.

    Health citation F-0921, Environmental Deficiencies. Inspection of August 28, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 22, 2025).

  3. 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 July 10, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 14, 2024).

  4. 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 August 3, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 14, 2023).

  5. 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 August 3, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 14, 2023).

  6. 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 August 3, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 14, 2023).

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

    Have exits that are accessible at all times.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0271, Egress Deficiencies. Inspection of August 28, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 9, 2025).

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

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0321, Smoke Deficiencies. Inspection of August 3, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 14, 2023).

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

    Install corridor and hallway doors that block smoke.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0363, Smoke Deficiencies. Inspection of August 3, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 14, 2023).

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

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

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

    Health citation F-0686, Quality of Life and Care Deficiencies. Inspection of July 10, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 9, 2024).

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

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

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

    Health citation F-0755, Pharmacy Service Deficiencies. Inspection of July 10, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 9, 2024).

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

    Ensure medication error rates are not 5 percent or greater.

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

    Health citation F-0759, Pharmacy Service Deficiencies. Inspection of July 10, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 9, 2024).

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

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

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

    Health citation F-0689, Quality of Life and Care Deficiencies. Inspection of May 30, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (July 1, 2024).

  14. No harm, with potential for minimal harm

    Provide and implement an infection prevention and control program.

    Widespread (many residents). CMS level C.

    Health citation F-0880, Infection Control Deficiencies. Inspection of August 3, 2023. Found during a standard inspection.

    The home has a plan to correct it (September 18, 2023).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.