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
Changed ownership
No
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
0.35
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.46
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.42
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
4.22
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.80
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.86
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.26
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.38
CMS adjusted RN staffing hours
Adjusted total hours
4.59
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
87%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,544
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.53
Composite VBP score used to determine payment impact.
Payment multiplier
0.9871
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.15% · Performance 22.60% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.79
Baseline 4.97% · Performance 6.70% · Measure score 3.79 · Achievement 3.79 · Improvement 0
Total nurse turnover
6.26
Baseline 32.91% · Performance 38.09% · Measure score 6.26 · Achievement 6.26 · Improvement 0
Adjusted total nurse staffing
2.96
Baseline 3.74 hours · Performance 3.92 hours · Measure score 2.96 · Achievement 2.96 · Improvement 0.38
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.67% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 136 · Observed rate 13.97% · Lower 95% interval 8.78% |
| Discharge to community | 60.3% |
50.57%
9.7 pts better
|
Better than the National Rate · Eligible stays 128 · Observed rate 57.03% · Lower 95% interval 52% |
| Medicare spending per beneficiary | 0.71 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 95.31% |
95.27%
About the same
|
Numerator 61 · Denominator 64 |
| Falls with major injury | 1.56% |
0.77%
0.8 pts worse
|
Numerator 1 · Denominator 64 |
| Discharge self-care score | 70% |
53.69%
16.3 pts better
|
Numerator 35 · Denominator 50 |
| Discharge mobility score | 78% |
50.94%
27.1 pts better
|
Numerator 39 · Denominator 50 |
| Pressure ulcers or injuries, new or worsened | 1.56% |
2.29%
0.7 pts better
|
Numerator 1 · Denominator 64 · Adjusted rate 1.57% |
| Healthcare-associated infections requiring hospitalization | 6.7% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 78 · Observed rate 5.13% · Lower 95% interval 4.01% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 60% |
56.45%
3.5 pts better
|
Numerator 30 · Denominator 50 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 41 · Denominator 41 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 55.56% |
25.2%
30.4 pts better
|
Numerator 15 · Denominator 27 |
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 · Adjusted 1.7 · Observed 1.5 · Expected 1.7 · Used in QM five-star |
| 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 · Adjusted 1.2 · Observed 1.0 · Expected 1.5 · 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 | 5.1% |
3.1%
2 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 4.8% · Q3 5.1% · Q4 3.2% · 4Q avg 5.1% · 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 | 4.4% |
5.5%
1.1 pts better
|
5.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 3.6% · Q3 5.7% · Q4 1.7% · 4Q avg 4.4% |
| 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 · Q1 10.3% · Q2 7.3% · Q3 7.5% · Q4 5.0% · 4Q avg 7.5% |
| 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 · Q1 12.0% · Q2 10.9% · Q3 4.9% · Q4 5.7% · 4Q avg 8.4% · 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 ability to walk independently worsened | 29.9% |
13.9%
16 pts worse
|
16.3%
13.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.5% · Q2 27.1% · Q3 24.5% · 4Q avg 29.9% · Used in QM five-star |
| 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 · Q1 27.8% · Q2 24.0% · Q3 21.3% · Q4 18.9% · 4Q avg 23.0% · 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 1.5% · 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 | 2.0% |
1.7%
0.3 pts worse
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 2.0% · Used in QM five-star |
| 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 · Q1 35.6% · Q2 27.1% · Q3 30.9% · Q4 20.8% · 4Q avg 28.8% |
| 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 · Q1 5.0% · Q2 5.3% · Q3 4.4% · Q4 1.4% · 4Q avg 4.0% · Used in QM five-star |
| 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 · Q1 97.1% · Q2 94.2% · Q3 94.2% · Q4 95.8% · 4Q avg 95.3% |
| 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 · Adjusted 19.7% · Observed 18.3% · Expected 10.4% · Used in QM five-star |
| 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 · Q1 1.4% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| 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 · 4Q avg 94.4% |
| 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 · Adjusted 23.6% · Observed 22.5% · Expected 22.8% · Used in QM five-star |
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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