Inspection visit
Inspection
Citations
12 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0222GeneralS&S Epotential for 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.
- 0223GeneralS&S Epotential for harm
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- 0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0342GeneralS&S Epotential for harm
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
- 0351GeneralS&S Fpotential for harm
Install an approved automatic sprinkler system.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0355GeneralS&S Epotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
F914 - Be designed or equipped to assure full visual privacy for each
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
F583 - Privacy and Confidentiality
Keep residents' personal and medical records private and confidential.
FAQ · About this visit
Common questions about this visit
What happened during the January 14, 2025 survey of Wellspring Lutheran Nursing and Rehab Services?
This was a inspection survey of Wellspring Lutheran Nursing and Rehab Services on January 14, 2025. The surveyor cited 12 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Wellspring Lutheran Nursing and Rehab Services on January 14, 2025?
Yes, 12 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "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 arra..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.