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Wellspring Lutheran Nursing and Rehab Services

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Wellspring Lutheran Nursing and Rehab Services is a non profit - corporation facility in Monroe, MI with 122 certified beds and a 5-star overall CMS rating. The facility has 4 deficiency records on file.

1236 S Monroe St, Monroe, MI 48161

Phone: 7342419533

Overall Rating

5/5

Health Inspection

5/5

Staffing

3/5

Quality Measures

4/5

Long-Stay Quality

3/5

Facility Information

Provider Number
235274
Ownership
Non profit - Corporation
Provider Type
Medicare and Medicaid
Beds
122
Residents
81
In Hospital
No
County
Monroe
Last Inspection
Jan 14, 2025

Staffing Data

RN Hours
0.35 (nat'l avg: 0.68)
LPN Hours
1.46
CNA Hours
2.42
Total Nursing Hours
4.22 (nat'l avg: 3.89)
PT Hours
0.07
Nursing Turnover
54.2%
RN Turnover
86.7%

What the CMS Record Reveals About Wellspring Lutheran Nursing and Rehab Services

Wellspring Lutheran Nursing and Rehab Services operates 122 certified beds in Monroe, MI with approximately 81 residents currently in care, and carries a CMS overall rating of 5 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (5★), staffing levels (3★), and quality measures (4★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.

The inspection file contains 4 deficiency records from recent surveys, all falling in the no-harm or minimal-harm bands of the CMS scope-and-severity grid. No fines or payment denials have been assessed against this provider, suggesting issues — if any — did not rise to the enforcement threshold. Staffing is reported at 4.22 total nursing hours per resident day (national average 3.89), with RN coverage at 0.35 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.

Classified as "Non profit - Corporation" ownership and operating as a "Medicare and Medicaid" provider, Wellspring Lutheran Nursing and Rehab Services falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 54.2%, above the level where continuity of care typically begins to suffer. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.

Deficiency History (4 most recent)

D — Isolated - Minimal harm Nov 21, 2025 Tag: 0658

Ensure services provided by the nursing facility meet professional standards of quality.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Dec 1, 2025

D — Isolated - Minimal harm Jan 14, 2025 Tag: 0583

Keep residents' personal and medical records private and confidential.

Category: Resident Rights Deficiencies

Corrected: Feb 21, 2025

D — Isolated - Minimal harm Dec 20, 2023 Tag: 0947

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Category: Nursing and Physician Services Deficiencies

Corrected: Jan 17, 2024

D — Isolated - Minimal harm Dec 20, 2023 Tag: 0644

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Jan 17, 2024

Quality Measures

Measure Type Score Used in Rating
Percentage of long-stay residents whose need for help with daily activities has increased Long Stay 23.0% Yes
Percentage of long-stay residents who lose too much weight Long Stay 4.4% No
Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay 0.4% Yes
Percentage of long-stay residents with a urinary tract infection Long Stay 2.0% Yes
Percentage of long-stay residents who have depressive symptoms Long Stay 0.0% No
Percentage of long-stay residents who were physically restrained Long Stay 0.0% No
Percentage of long-stay residents experiencing one or more falls with major injury Long Stay 5.1% Yes
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine Long Stay 100.0% No
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine Short Stay 95.3% No
Percentage of short-stay residents who newly received an antipsychotic medication Short Stay 0.7% Yes
Percentage of long-stay residents whose ability to walk independently worsened Long Stay 29.9% Yes
Percentage of long-stay residents who received an antianxiety or hypnotic medication Long Stay 7.5% No
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine Long Stay 100.0% No
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine Short Stay 94.4% No
Percentage of long-stay residents with pressure ulcers Long Stay 4.0% Yes
Percentage of long-stay residents with new or worsened bowel or bladder incontinence Long Stay 28.8% No
Percentage of long-stay residents who received an antipsychotic medication Long Stay 8.4% Yes

Penalty History

No penalties on record.

Frequently Asked Questions

What is the overall CMS rating for Wellspring Lutheran Nursing and Rehab Services?
Wellspring Lutheran Nursing and Rehab Services has an overall CMS rating of 5 out of 5 stars. This rating combines health inspection results (5★), staffing levels (3★), and quality measures (4★).
What are the staffing levels at Wellspring Lutheran Nursing and Rehab Services?
Wellspring Lutheran Nursing and Rehab Services reports 4.22 total nursing hours per resident day (national average: 3.89). RN hours are 0.35 per resident day (national average: 0.68). Nursing staff turnover is 54.2%.
How many beds does Wellspring Lutheran Nursing and Rehab Services have?
Wellspring Lutheran Nursing and Rehab Services has 122 certified beds with approximately 81 residents. The facility is located at 1236 S Monroe St, Monroe, MI 48161.
Does Wellspring Lutheran Nursing and Rehab Services have any deficiencies on record?
Yes, Wellspring Lutheran Nursing and Rehab Services has 4 deficiencies on record from recent inspections. Most deficiencies are classified as no harm or minimal harm.
Has Wellspring Lutheran Nursing and Rehab Services received any fines or penalties?
No, Wellspring Lutheran Nursing and Rehab Services has no fines or penalties on record.
Who owns Wellspring Lutheran Nursing and Rehab Services?
Wellspring Lutheran Nursing and Rehab Services is classified as "Non profit - Corporation" ownership. The facility type is "Medicare and Medicaid".
When was Wellspring Lutheran Nursing and Rehab Services last inspected?
The most recent health inspection for Wellspring Lutheran Nursing and Rehab Services was on Jan 14, 2025. The facility received a health inspection rating of 5 out of 5 stars.
What quality measures are tracked for Wellspring Lutheran Nursing and Rehab Services?
Wellspring Lutheran Nursing and Rehab Services is evaluated on 17 quality measures, of which 8 are used in the CMS star rating calculation. These include measures for both long-stay and short-stay residents covering areas like infections, falls, pressure ulcers, and medication use.

Data Sources

Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.

Related

Data sourced from official U.S. government datasets. See our methodology for details. Retrieved and formatted by PlainNursing Editorial