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Wellspring Lutheran Services

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About Wellspring Lutheran Services

General Information

Legal Business NameAusable Valley Continuing Care Retirement Community Inc
Ownership TypeNon Profit - Corporation
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareApril 18, 1979 (38 years)
Capacity62
Residents44
Percent Occupied71%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsResident
In HospitalNo
Continuing Care Retirement CommunityYes
Special Focus FacilityNo
Auto Sprinkler System In Required AreasYes

Ratings for Wellspring Lutheran Services

Wellspring Lutheran Services
was reviewed by Medicare to have a rating of 4 out of 5. About Medicare Ratings
Overall Rating
Health Inspections Rating
Quality Measures Rating
Staff Rating
RN Staff Rating

Overall Ratings of Michigan Nursing Homes

Fines, Complaints, and Inspection Problems in the Past 3 Years

Compare The Number of Problems

Types of Problems at Nursing Homes

Some issues within a nursing home are much more severe than others. Medicare evaluates each problem based on 2 scales: the number of residents affected by a problem and the severity of the potential or actual harm to residents based on the problem. We have color coded the matrix below to make it easier to pick out the more severe problems. In general, orange and red issues related to the treatment of a resident are considered substandard quality of care.

  Residents Affected
Severity of the Deficiency Few Some Many
Immediate jeopardy to resident health or safety J K L
Actual harm that is not immediate jeopardy G H I
No actual harm with potential for more than minimal harm that is not immediate jeopardy D E F
No actual harm with potential for minimal harm A B C

September 17, 2015 - 15 months ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintGive or get x-rays and other tests in a timely manner to meet the needs of residents.

June 4, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmFire Safety InspectionAutomatic sprinkler systems that have been maintained in working order.
FManyPotential for HarmFire Safety InspectionSpecial areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system.
FManyPotential for HarmFire Safety InspectionCorridor and hallway doors that block smoke.
FManyPotential for HarmFire Safety InspectionCorridors that are separated from use areas by walls constructed to limit the passage of smoke.

May 28, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
CManyPotential for Minimal HarmHealth InspectionPost nurse staffing information/data on a daily basis.
DFewPotential for HarmComplaint+InspectionEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.

March 5, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
GFewActual HarmComplaintEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
DFewPotential for HarmComplaintDevelop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.
DFewPotential for HarmComplaint1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.

September 5, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintDevelop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.
ESomePotential for HarmComplaint1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.

August 20, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

May 29, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmFire Safety InspectionRecord of quarterly fire drills for each shift under varying conditions.
FManyPotential for HarmFire Safety InspectionA written emergency evacuation plan.
ESomePotential for HarmFire Safety InspectionPortable fire extinguishers.
DFewPotential for HarmComplaint+InspectionDevelop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.
DFewPotential for HarmComplaint+Inspection1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.
DFewPotential for HarmFire Safety InspectionProperly installed electrical wiring and equipment.

November 8, 2013 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
---Payment DenialPayment denial for 11 days
---Fine$17,945 fine

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of Wellspring Lutheran Services require. It is important to compare the reported time to expected time for a single facility instead of comparing the amount of time per resident of two facilities. Learn why.

2hr 40min
2hr 35min
ReportedExpected
CNA
50min
35min
ReportedExpected
LPN
1hr 5min
55min
ReportedExpected
RN
4hr 40min
4hr 5min
ReportedExpected
Total Nursing

This facility also provides approximately 15min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

100.0%
100.0%
100.0%
92.8%
Q1 2015Q2 2015Q3 2015MI
Assessed and Appropriately Given the Seasonal Influenza Vaccine
100.0%
97.7%
100.0%
93.6%
Q1 2015Q2 2015Q3 2015MI
Assessed and Appropriately Given the Pneumococcal Vaccine
-
-
-
48.9%
Q1 2015Q2 2015Q3 2015MI
* The data for this facility for some quarters is unavailable.
Low Risk Residents Who Lose Control of Their Bowel or Bladder
15.8%
11.6%
12.5%
13.8%
Q1 2015Q2 2015Q3 2015MI
Received an Antipsychotic Medication
6.5%
12.1%
-
14.1%
Q1 2015Q2 2015Q3 2015MI
* The data for this facility for some quarters is unavailable.
Need for Help with ADLs has Increased
6.7%
13.9%
8.0%
8.2%
Q1 2015Q2 2015Q3 2015MI
Self Report Moderate to Severe Pain
10.5%
4.7%
2.5%
7.9%
Q1 2015Q2 2015Q3 2015MI
Lose Too Much Weight
9.4%
5.6%
11.4%
5.9%
Q1 2015Q2 2015Q3 2015MI
High Risk Residents With Pressure Ulcers
5.4%
2.5%
0.0%
3.3%
Q1 2015Q2 2015Q3 2015MI
Have Depressive Symptoms
5.3%
18.6%
5.0%
4.9%
Q1 2015Q2 2015Q3 2015MI
With a Urinary Tract Infection
7.9%
4.7%
7.5%
3.0%
Q1 2015Q2 2015Q3 2015MI
Experiencing One or More Falls with Major Injury
2.7%
2.2%
0.0%
3.4%
Q1 2015Q2 2015Q3 2015MI
With a Catheter Inserted and Left in Their Bladder
0.0%
0.0%
0.0%
1.1%
Q1 2015Q2 2015Q3 2015MI
Were Physically Restrained

Quality Measures for Short Stay Residents

96.2%
97.6%
98.0%
81.6%
Q1 2015Q2 2015Q3 2015MI
Assessed and Appropriately Given the Pneumococcal Vaccine
96.2%
96.2%
96.2%
80.9%
Q1 2015Q2 2015Q3 2015MI
Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
17.0%
21.2%
25.0%
18.0%
Q1 2015Q2 2015Q3 2015MI
Self Report Moderate to Severe Pain
0.0%
0.0%
3.4%
1.8%
Q1 2015Q2 2015Q3 2015MI
Newly Received an Antipsychotic Medication
1.5%
3.2%
2.5%
1.1%
Q1 2015Q2 2015Q3 2015MI
With Pressure Ulcers That Are New or Worsened