Cycle 1
Health 2025-01-14 · Fire 2025-01-14
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
11 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Monroe, MI
Wellspring Lutheran Nursing and Rehab Services
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
1236 S Monroe St, Monroe, MI
(734) 241-9533
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
122
Certified beds
Average residents
81
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1976-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.35
Registered nurse staffing
LPN hours / resident day
1.46
Licensed practical nurse staffing
Aide hours / resident day
2.42
Nurse aide staffing
Weekend hours
3.86
Weekend nurse staffing
RN turnover
87%
Annual RN turnover
Total nurse turnover
54%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.7
About the same
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.5
0.3 pts better
|
1.8
0.6 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 | 5.1% |
3.1%
2 pts worse
|
3.3%
1.8 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 | 4.4% |
5.5%
1.1 pts better
|
5.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.5% |
19.6%
12.1 pts better
|
19.6%
12.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 8.4% |
16.5%
8.1 pts better
|
16.7%
8.3 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 ability to walk independently worsened | 29.9% |
13.9%
16 pts worse
|
16.3%
13.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.0% |
11.7%
11.3 pts worse
|
14.9%
8.1 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 | 2.0% |
1.7%
0.3 pts worse
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.8% |
20.4%
8.4 pts worse
|
19.8%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
5.6%
1.6 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.3% |
82.8%
12.5 pts better
|
81.7%
13.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.7% |
11.5%
8.2 pts worse
|
12.0%
7.7 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.3%
0.6 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.4% |
79.5%
14.9 pts better
|
79.7%
14.7 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.6% |
24.2%
0.6 pts better
|
23.9%
0.3 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-20 · Fire 2023-12-20
3 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
10 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2023-03-15 · Fire 2023-03-15
0 health deficiencies
No concentrated health issue counts in this cycle.
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-14
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-04-30
F · Potential for more than minimal harm
2025-01-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-01-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-01-14
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 2025-02-28
E · Potential for more than minimal harm
2025-01-14
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-01-14
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 2025-02-28
E · Potential for more than minimal harm
2025-01-14
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-01-14
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-01-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-01-14
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-01-14
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-02-28
F · Potential for more than minimal harm
2023-12-20
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2024-01-17
F · Potential for more than minimal harm
2023-12-20
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-01-17
F · Potential for more than minimal harm
2023-12-20
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-01-17
F · Potential for more than minimal harm
2023-12-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-17
F · Potential for more than minimal harm
2023-12-20
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-01-17
F · Potential for more than minimal harm
2023-12-20
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-01-17
F · Potential for more than minimal harm
2023-12-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-01-17
E · Potential for more than minimal harm
2023-12-20
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-12-20
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-01-17
E · Potential for more than minimal harm
2023-12-20
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-01-17
F · Potential for more than minimal harm
2023-03-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-04-20
F · Potential for more than minimal harm
2023-03-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-20
F · Potential for more than minimal harm
2023-03-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-20
F · Potential for more than minimal harm
2023-03-15
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-04-20
F · Potential for more than minimal harm
2023-03-15
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-04-20
F · Potential for more than minimal harm
2023-03-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-04-20
E · Potential for more than minimal harm
2023-03-15
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-04-20
E · Potential for more than minimal harm
2023-03-15
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 2023-04-20
D · Potential for more than minimal harm
2023-03-15
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-04-20
D · Potential for more than minimal harm
2023-03-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-04-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-21
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-12-01
D · Potential for more than minimal harm
2025-01-14
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-02-21
D · Potential for more than minimal harm
2023-12-20
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-12-20
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-01-17
Penalties and ownership
What sits behind the stars
Ownership
Bender, Peter
Corporate Director · Individual
Benko, Amy
Corporate Director · Individual
Cassidy, Bruce
Operational/Managerial Control · Individual
Cushway, Ritch
Corporate Director · Individual
Gehm, David
Operational/Managerial Control · Individual
Gehm, David
Corporate Director · Individual
Gehm, David
Corporate Officer · Individual
Kalbfleisch, Timothy
Operational/Managerial Control · Individual
Kalbfleisch, Timothy
Corporate Officer · Individual
Logan, Andrea
Corporate Director · Individual
Nyquist, Paul
Corporate Director · Individual
Piccininni, Judy
Operational/Managerial Control · Individual
Schoenow, Carl
Corporate Director · Individual
Storck, Karen
Corporate Director · Individual
Terry, Stephen
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
IHM Senior Living Community
Monroe, MI
5-star overall rating with 5-star inspections with 3 fire-safety deficiencies in the latest cycle
#2
Medilodge of Monroe
Monroe, MI
4-star overall rating with 4-star inspections with 1 recent health deficiencies
#3
Seacrest Rehabilitation and Nursing Center
Monroe, MI
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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