Frankenmuth, MI

Wellspring Lutheran Services

3-star overall rating with 3-star inspections with 11 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

725 West Genesee, Frankenmuth, MI

(989) 652-9951

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1976-03-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.66

Registered nurse staffing · state 0.77 · national 0.68

LPN hours / resident day

0.90

Licensed practical nurse staffing · state 0.88 · national 0.87

Aide hours / resident day

2.82

Nurse aide staffing · state 2.38 · national 2.35

Total nurse hours

4.38

All reported nurse hours · state 4.03 · national 3.89

Licensed hours

1.56

RN + LPN hours · state 1.65 · national 1.54

Weekend hours

3.98

Weekend nurse staffing · state 3.52 · national 3.43

Weekend RN hours

0.44

Weekend registered nurse coverage · state 0.49 · national 0.47

Physical therapist

0.04

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.69

CMS adjusted RN staffing hours

Adjusted total hours

4.52

CMS adjusted total nurse staffing hours

Case-mix index

1.32

Higher values indicate more complex resident acuity

RN turnover

47%

Annual RN turnover · state 41% · national 45%

Total nurse turnover

56%

Annual nurse turnover · state 44% · national 46%

SNF VBP

Value-based purchasing

Program rank

8,777

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

25.72

Composite VBP score used to determine payment impact.

Payment multiplier

0.9839

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 21.28% · Performance 22.32% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

Baseline 5.28% · Performance 8.41% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

4.37

Baseline 47.37% · Performance 45.83% · Measure score 4.37 · Achievement 4.37 · Improvement 0.18

Adjusted total nurse staffing

5.92

Baseline 4.36 hours · Performance 4.76 hours · Measure score 5.92 · Achievement 5.92 · Improvement 2.32

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.55%	10.72% 0.8 pts worse	No Different than the National Rate · Eligible stays 144 · Observed rate 11.11% · Lower 95% interval 8.79%
Discharge to community	57.15%	50.57% 6.6 pts better	Better than the National Rate · Eligible stays 137 · Observed rate 56.2% · Lower 95% interval 50.73%
Medicare spending per beneficiary	0.83	1.02 0.2 pts better
Drug regimen review with follow-up	97.4%	95.27% 2.1 pts better	Numerator 75 · Denominator 77
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 77
Discharge self-care score	50.91%	53.69% 2.8 pts worse	Numerator 28 · Denominator 55
Discharge mobility score	47.27%	50.94% 3.7 pts worse	Numerator 26 · Denominator 55
Pressure ulcers or injuries, new or worsened	1.3%	2.29% 1 pts better	Numerator 1 · Denominator 77 · Adjusted rate 1.25%
Healthcare-associated infections requiring hospitalization	8.41%	7.12% 1.3 pts worse	No Different than the National Rate · Eligible stays 79 · Observed rate 8.86% · Lower 95% interval 4.92%
Staff COVID-19 vaccination coverage	13.64%	8.2% 5.4 pts better	Numerator 15 · Denominator 110
Staff flu vaccination coverage	20.13%	42% 21.9 pts worse	Numerator 32 · Denominator 159
Discharge function score	38.18%	56.45% 18.3 pts worse	Numerator 21 · Denominator 55
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 52 · Denominator 52
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	42.86%	25.2% 17.7 pts better	Numerator 18 · Denominator 42

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.5	1.7 0.8 pts worse	1.9 0.6 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 1.8 · Expected 1.4 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.9	1.5 0.6 pts better	1.8 0.9 pts better	Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.7 · Expected 1.3 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	95.0% 5 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	95.0% 5 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	5.9%	3.1% 2.8 pts worse	3.3% 2.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 10.3% · Q3 7.1% · Q4 2.8% · 4Q avg 5.9% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.0%	4.1% 4.1 pts better	11.4% 11.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents who lose too much weight	6.2%	5.5% 0.7 pts worse	5.4% 0.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 0.0% · Q3 6.7% · Q4 12.0% · 4Q avg 6.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	10.6%	19.6% 9 pts better	19.6% 9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 6.9% · Q3 9.7% · Q4 16.0% · 4Q avg 10.6%
Percentage of long-stay residents who received an antipsychotic medication	6.0%	16.5% 10.5 pts better	16.7% 10.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 9.1% · Q3 4.5% · 4Q avg 6.0% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose need for help with daily activities has increased	18.3%	11.7% 6.6 pts worse	14.9% 3.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 29.6% · Q3 14.3% · Q4 8.3% · 4Q avg 18.3% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.4%	0.9% 0.5 pts better	1.0% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	4.6%	1.7% 2.9 pts worse	1.7% 2.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 0.0% · Q3 7.3% · Q4 8.3% · 4Q avg 4.6% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	33.8%	20.4% 13.4 pts worse	19.8% 14 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 49.7% · Q2 27.8% · Q3 35.1% · Q4 22.6% · 4Q avg 33.8%
Percentage of long-stay residents with pressure ulcers	11.6%	5.6% 6 pts worse	5.1% 6.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 13.0% · Q3 13.8% · Q4 9.4% · 4Q avg 11.6% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	96.8%	82.8% 14 pts better	81.7% 15.1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 92.5% · Q2 97.2% · Q3 98.5% · Q4 98.7% · 4Q avg 96.8%
Percentage of short-stay residents who had an outpatient emergency department visit	2.9%	11.5% 8.6 pts better	12.0% 9.1 pts better	Short Stay · 20240701-20250630 · Adjusted 2.9% · Observed 2.9% · Expected 11.2% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.4%	1.3% 0.1 pts worse	1.6% 0.2 pts better	Short Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.2% · Q3 0.0% · Q4 1.0% · 4Q avg 1.4% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	96.6%	79.5% 17.1 pts better	79.7% 16.9 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 96.6%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	24.3%	24.2% 0.1 pts worse	23.9% 0.4 pts worse	Short Stay · 20240701-20250630 · Adjusted 24.3% · Observed 26.1% · Expected 25.6% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-08-14 · Fire 2025-08-14

11 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2024-07-25 · Fire 2024-07-25

10 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

6 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2023-08-04 · Fire 2023-08-04

5 health deficiencies

Top issue: Nutrition and Dietary (2 deficiencies)

6 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-08-14

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-09-23

F · Potential for more than minimal harm 2025-08-14

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-09-23

D · Potential for more than minimal harm 2025-08-14

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-09-23

F · Potential for more than minimal harm 2024-07-25

E15 · Emergency Preparedness Deficiencies

Fire Safety

Address subsistence needs for staff and patients.

Corrected 2024-08-28

F · Potential for more than minimal harm 2024-07-25

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2024-08-28

F · Potential for more than minimal harm 2024-07-25

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-08-28

F · Potential for more than minimal harm 2024-07-25

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-08-28

F · Potential for more than minimal harm 2024-07-25

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2024-08-28

E · Potential for more than minimal harm 2024-07-25

K232 · Egress Deficiencies

Fire Safety

Have corridors or aisles that are unobstructed and are at least 8 feet in width.

Corrected 2024-08-28

F · Potential for more than minimal harm 2023-08-04

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-09-12

E · Potential for more than minimal harm 2023-08-04

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2023-09-12

E · Potential for more than minimal harm 2023-08-04

K222 · Egress Deficiencies

Fire Safety

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.

Corrected 2023-11-27

E · Potential for more than minimal harm 2023-08-04

K321 · Smoke Deficiencies

Fire Safety

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

Corrected 2023-09-12

E · Potential for more than minimal harm 2023-08-04

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-09-12

E · Potential for more than minimal harm 2023-08-04

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Corrected 2023-09-12

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-08-14

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2025-09-23

E · Potential for more than minimal harm 2025-08-14

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2025-09-23

E · Potential for more than minimal harm 2025-08-14

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2025-09-23

E · Potential for more than minimal harm 2025-08-14

F921 · Environmental Deficiencies

Health

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

Corrected 2025-09-23

D · Potential for more than minimal harm 2025-08-14

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2025-09-23

D · Potential for more than minimal harm 2025-08-14

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2025-09-23

D · Potential for more than minimal harm 2025-08-14

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-09-23

D · Potential for more than minimal harm 2025-08-14

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-09-23

D · Potential for more than minimal harm 2025-08-14

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2025-09-23

D · Potential for more than minimal harm 2025-08-14

F694 · Quality of Life and Care Deficiencies

Health

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Corrected 2025-09-23

D · Potential for more than minimal harm 2025-08-14

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2025-09-23

F · Potential for more than minimal harm 2024-07-25

F921 · Environmental Deficiencies

Health

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

Corrected 2024-08-28

E · Potential for more than minimal harm 2024-07-25

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-08-28