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

Staffing

Hours and turnover

RN hours / resident day

0.66

Registered nurse staffing

LPN hours / resident day

0.90

Licensed practical nurse staffing

Aide hours / resident day

2.82

Nurse aide staffing

Weekend hours

3.98

Weekend nurse staffing

RN turnover

47%

Annual RN turnover

Total nurse turnover

56%

Annual nurse turnover

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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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

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