Federal inspection record · CMS data as of October 1, 2026
Wellspring Lutheran Nursing and Rehab Services
1236 S Monroe St, Monroe, MI · (734) 241-9533
- Certified beds
- 122
- Residents per day
- 81
- Ownership
- Non-Profit
- Chain
- No chain reported
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- April 1, 1976
1
How this home got 5 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Michigan.
-
Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★5 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Michigan homes
Wellspring Lutheran Nursing and Rehab Services carries 16 inspection points. That is fewer than 91% of Michigan's 420 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Michigan: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–18 pts
- 4★ 18–46 pts
- 3★ 46–78 pts
- 2★ 78–123 pts
- 1★ over 123 pts
Bars show every rated home in Michigan by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
6 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
No citation on record at the harm or immediate-jeopardy level.
Everything else, by area of care
Resident Rights2E
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Keep residents' personal and medical records private and confidential.
Resident Assessment and Care Planning2D
- D
Ensure services provided by the nursing facility meet professional standards of quality.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Infection Control1E
- E
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Nursing and Physician Services1D
- D
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspection history
2026-03-19
3 health deficiencies · 15 fire-safety deficiencies
Top issue: Infection Control (1 deficiency)
2025-01-14
1 health deficiencies · 11 fire-safety deficiencies
Top issue: Resident Rights (1 deficiency)
2023-12-20
2 health deficiencies · 10 fire-safety deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
4
Nursing time per resident, per day
Each resident here gets about 3 h 53 min of nursing staff time a day, 34 min of it from a registered nurse.
This home
3 h 53 min
Michigan average
4 h 2 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 52% of nursing staff and 67% of registered nurses left in the past year, along with 2 administrators.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.2 pts worse | 1.9 | 1.7 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.1 pts better | 1.5 | 1.6 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine3 pts better | 98.4% | 95.4% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine3 pts better | 98.5% | 95.5% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury1.3 pts worse | 4.3% | 3.0% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms4.5 pts better | 0.0% | 4.5% | 13.5% |
| Percentage of long-stay residents who lose too much weight2.5 pts better | 3.0% | 5.5% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication8.7 pts better | 10.7% | 19.4% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication8.6 pts better | 6.1% | 14.7% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened18.9 pts worse | 30.0% | 11.1% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased15 pts worse | 25.7% | 10.7% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.7 pts better | 0.0% | 0.7% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.3 pts better | 1.2% | 1.5% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence9.6 pts worse | 29.0% | 19.4% | 18.3% |
| Percentage of long-stay residents with pressure ulcers4.3 pts better | 0.7% | 5.0% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine12.5 pts better | 95.9% | 83.4% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit2.1 pts worse | 13.8% | 11.7% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.5 pts better | 0.6% | 1.1% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine7.8 pts better | 89.3% | 81.5% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission1.5 pts worse | 25.4% | 23.9% | 23.4% |
·
Who owns and runs it
28 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Bender, Peter | Managing Control - Governing Body · Individual | 0% | 3 facilities |
| Bender, Peter | Corporate Director · Individual | 0% | 3 facilities |
| Benko, Amy | Managing Control - Governing Body · Individual | 0% | 3 facilities |
| Benko, Amy | Corporate Director · Individual | 0% | 3 facilities |
| Cassidy, Bruce | Operational/Managerial Control · Individual | 0% | 2 facilities |
| Cassidy, Bruce | Adp Of The SNF · Individual | 0% | 2 facilities |
| Cushway, Ritch | Managing Control - Governing Body · Individual | 0% | 3 facilities |
| Cushway, Ritch | Corporate Director · Individual | 0% | 3 facilities |
| Gehm, David | Managing Control - Governing Body · Individual | 0% | 4 facilities |
| Gehm, David | Corporate Director · Individual | 0% | 4 facilities |
| Gehm, David | Corporate Officer · Individual | 0% | 4 facilities |
| Gehm, David | Operational/Managerial Control · Individual | 0% | 4 facilities |
| Gehm, David | Adp Of The SNF · Individual | 0% | 4 facilities |
| Kalbfleisch, Timothy | Corporate Officer · Individual | 0% | 3 facilities |
| Kalbfleisch, Timothy | Operational/Managerial Control · Individual | 0% | 3 facilities |
| Kalbfleisch, Timothy | Adp Of The SNF · Individual | 0% | 3 facilities |
| Logan, Andrea | Managing Control - Governing Body · Individual | 0% | 2 facilities |
| Logan, Andrea | Corporate Director · Individual | 0% | 2 facilities |
| Nyquist, Paul | Managing Control - Governing Body · Individual | 0% | 3 facilities |
| Nyquist, Paul | Corporate Director · Individual | 0% | 3 facilities |
| Piccininni, Judy | Operational/Managerial Control · Individual | 0% | 2 facilities |
| Piccininni, Judy | Adp Of The SNF · Individual | 0% | 2 facilities |
| Schoenow, Carl | Managing Control - Governing Body · Individual | 0% | 3 facilities |
| Schoenow, Carl | Corporate Director · Individual | 0% | 3 facilities |
| Storck, Karen | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Storck, Karen | Corporate Director · Individual | 0% | 1 facilities |
| Terry, Stephen | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Terry, Stephen | Adp Of The SNF · Individual | 0% | 1 facilities |
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Fire safety
36 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke13F
- F
Provide properly protected cooking facilities.
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- F
Inspect, test, and maintain automatic sprinkler systems.
- F
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
- F
Install corridor and hallway doors that block smoke.
- F
Install an approved automatic sprinkler system.
- F
Inspect, test, and maintain automatic sprinkler systems.
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
- E
Install corridor and hallway doors that block smoke.
- F
Inspect, test, and maintain automatic sprinkler systems.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Emergency Preparedness8F
- F
Establish procedures for tracking staff and patients during an emergency.
- F
Establish policies and procedures for volunteers.
- F
Establish roles under a Waiver declared by secretary.
- F
Establish emergency prep training and testing.
- F
Conduct testing and exercise requirements.
- F
Develop and maintain an Emergency Preparedness Program (EP).
- F
Develop a communication plan.
- F
Develop and maintain an Emergency Preparedness Program (EP).
Egress5F
- D
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.
- E
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.
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- F
Install emergency lighting that can last at least 1 1/2 hours.
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Gas, Vacuum, and Electrical Systems4F
- F
Ensure proper usage of power strips and extension cords.
- E
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- E
Have proper medical gas storage and administration areas.
- F
Have generator or other power source capable of supplying service within 10 seconds.
Services3F
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- D
Have properly installed electrical wiring and gas equipment.
- E
Have properly installed electrical wiring and gas equipment.
Miscellaneous3F
- F
Have simulated fire drills held at unexpected times.
- F
Provide a written emergency evacuation plan.
- F
Have restrictions on the use of highly flammable decorations.
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Other homes nearby
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IHM Senior Living Community
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★★★★★- Worst citation, 3 yrs
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- Nursing / resident / day
- 4 h 34 min
- Fines
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-
Medilodge of Monroe
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- Fines
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-
Seacrest Rehabilitation and Nursing Center
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★★★★★- Worst citation, 3 yrs
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- Nursing / resident / day
- 3 h 30 min
- Fines
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