CCN 235274
Wellspring Lutheran Nursing and Rehab Services
1236 S Monroe St, Monroe, MI 48161 · Monroe County
- Ownership
- Non profit - Corporation
- Certified beds
- 122
- Residents per day
- 82.9
- Health citations
- 6
- Penalties
- 0
- Fines
- 0 · $0
Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections
Staffing hours
Reported hours per resident per day come from the Payroll-Based Journal figures in the Provider Information file. Case-mix and adjusted hours account for how much care CMS expects given the residents’ needs. State and U.S. figures are averages from the same release.
- Measure
- This home
- State
- U.S.
- Nurse aide
- 1.05
- 2.33
- 2.32
- LPN/LVN
- 0.73
- 0.88
- 0.86
- Registered nurse
- 0.32
- 0.78
- 0.69
- Total nurse staff
- 2.10
- 3.99
- 3.86
- Weekend total
- 1.75
- 3.50
- 3.42
- Weekend RN
- 0.22
- 0.49
- 0.48
Adjusted total nurse hours: 2.24. Adjusted RN hours: 0.35. Case-mix total: 3.60. Case-mix index: 1.315.
Total nursing staff turnover: 53.3%. RN turnover: 92.9%. Administrators who left: 1.
How to read staffing hours
Payroll-Based Journal figures in Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections
Fines and penalties
CMS reports 0 fines totaling $0, and 0 payment denials.
The Penalties file has no individual penalty rows for this CCN.
Cycle 1 standard survey: March 19, 2026. Health deficiencies counted in cycle 1: 3. Cycle 1 total health score: 20.
Cycle 2 standard survey: January 14, 2025. Cycle 2/3 health deficiencies: 1. Total weighted health survey score: 16.
Penalties file and Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections
Health inspection citations
The Health Deficiencies file lists 6 citations for this home, including 0 at immediate jeopardy and 0 at actual harm. CMS may display some citations here that are not used in the health inspection rating, including citations under dispute.
March 19, 2026
2 citations
| Tag | What CMS cited | Scope and severity | Status |
|---|
| F550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Standard survey · Cycle 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · April 21, 2026 |
| F887 | 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. Infection Control Deficiencies · Standard survey · Cycle 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · April 21, 2026 |
November 21, 2025
1 citation
| Tag | What CMS cited | Scope and severity | Status |
|---|
| F658 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Complaint survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 1, 2025 |
January 14, 2025
1 citation
| Tag | What CMS cited | Scope and severity | Status |
|---|
| F583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · Complaint survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · February 21, 2025 |
December 20, 2023
2 citations
| Tag | What CMS cited | Scope and severity | Status |
|---|
| F644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · January 17, 2024 |
| F947 | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Nursing and Physician Services Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · January 17, 2024 |
Health Deficiencies. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections