Cycle 1
Health 2025-08-28 · Fire 2025-08-28
1 health deficiencies
Top issue: Environmental (1 deficiency)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fairview, MI
Wellspring Lutheran Services
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1390 Maple Drive, Fairview, MI
(989) 848-2241
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
39
Certified beds
Average residents
37
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1979-04-18
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
1.01
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.71
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
4.15
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.72
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.25
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.38
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.11
CMS adjusted RN staffing hours
Adjusted total hours
4.54
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,141
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
59.50
Composite VBP score used to determine payment impact.
Payment multiplier
1.0147
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
6.17
Baseline 46.51% · Performance 38.46% · Measure score 6.17 · Achievement 6.17 · Improvement 3.22
Adjusted total nurse staffing
5.73
Baseline 4.56 hours · Performance 4.71 hours · Measure score 5.73 · Achievement 5.73 · Improvement 0.74
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.38% |
10.72%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 49 · Observed rate 18.37% · Lower 95% interval 8.38% |
| Discharge to community | 60.85% |
50.57%
10.3 pts better
|
No Different than the National Rate · Eligible stays 39 · Observed rate 64.1% · Lower 95% interval 49.86% |
| Medicare spending per beneficiary | 0.7 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 32 · Denominator 32 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 32 |
| Discharge self-care score | 42.86% |
53.69%
10.8 pts worse
|
Numerator 12 · Denominator 28 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 14 · Denominator 28 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 32 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 11.86% |
8.2%
3.7 pts better
|
Numerator 7 · Denominator 59 |
| Staff flu vaccination coverage | 37.68% |
42%
4.3 pts worse
|
Numerator 26 · Denominator 69 |
| Discharge function score | 46.43% |
56.45%
10 pts worse
|
Numerator 13 · Denominator 28 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 20 · Denominator 20 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 20 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
95.0%
4.1 pts better
|
93.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.3% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.1% |
| 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 | 4.5% |
3.1%
1.4 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.2% · Q3 6.9% · Q4 6.2% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.9% |
4.1%
2.2 pts better
|
11.4%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.6% · Q4 3.4% · 4Q avg 1.9% |
| Percentage of long-stay residents who lose too much weight | 7.6% |
5.5%
2.1 pts worse
|
5.4%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 9.5% · Q3 8.3% · Q4 12.0% · 4Q avg 7.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 37.0% |
19.6%
17.4 pts worse
|
19.6%
17.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.4% · Q2 42.9% · Q3 33.3% · Q4 36.0% · 4Q avg 37.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.4% |
16.5%
3.1 pts better
|
16.7%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 9.1% · Q4 13.6% · 4Q avg 13.4% · 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 | 7.2% |
13.9%
6.7 pts better
|
16.3%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.6% |
11.7%
4.1 pts better
|
14.9%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 5.0% · Q4 4.5% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
1.7%
0.1 pts worse
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 0.0% · Q3 3.4% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 34.1% |
20.4%
13.7 pts worse
|
19.8%
14.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 46.4% · Q2 21.3% · Q3 39.5% · Q4 29.0% · 4Q avg 34.1% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
5.6%
1.9 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 0.0% · Q3 6.3% · Q4 0.0% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.7% |
82.8%
14.9 pts better
|
81.7%
16 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.5% · Q2 96.7% · Q3 100.0% · Q4 100.0% · 4Q avg 97.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.7% |
11.5%
0.2 pts worse
|
12.0%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.7% · Observed 12.0% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.3%
0.5 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.4% |
79.5%
13.9 pts better
|
79.7%
13.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 11.1% |
24.2%
13.1 pts better
|
23.9%
12.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.1% · Observed 12.0% · Expected 25.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-10 · Fire 2024-07-10
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-08-03 · Fire 2023-08-03
1 health deficiencies
Top issue: Infection Control (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-08-28
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-10-09
F · Potential for more than minimal harm
2024-07-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-14
F · Potential for more than minimal harm
2023-08-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-14
F · Potential for more than minimal harm
2023-08-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-14
F · Potential for more than minimal harm
2023-08-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-14
E · Potential for more than minimal harm
2023-08-03
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 2023-09-14
E · Potential for more than minimal harm
2023-08-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-14
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-08-28
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 2025-09-22
G · Actual harm
2025-02-06
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 2025-03-12
D · Potential for more than minimal harm
2024-07-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-10
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-10
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-05-30
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 2024-07-01
C · Minimal harm
2023-08-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-18
Penalties and ownership
What sits behind the stars
$0
2025-02-06
Payment Denial
Payment Denial · denial start 2025-03-05 · 7 days
7 day denial
Ownership
Lutheran Homes Of Michigan, Inc
5% Or Greater Direct Ownership Interest · Organization
Bender, Peter
Corporate Director · Individual
Benko, Amy
Corporate Director · Individual
Cushway, Ritch
Corporate Director · Individual
Dargis, David
Operational/Managerial Control · Individual
Gehm, David
Operational/Managerial Control · Individual
Gehm, David
Corporate Officer · Individual
Kalbfleisch, Timothy
Corporate Officer · Individual
Logan, Andrea
Corporate Director · Individual
Naffien, Fawn
Operational/Managerial Control · Individual
Nyquist, Paul
Corporate Director · Individual
Schoenow, Carl
Corporate Director · Individual
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#3
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4-star overall rating with 4-star inspections with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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