Wellspring Lutheran Nursing and Rehab Services
1236 S Monroe St, Monroe, MI 48161
Wellspring Lutheran Nursing and Rehab Services is a nursing home in Monroe, Michigan. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 5 of 5CMS overall star rating
- 5 of 5CMS health inspection star rating
- 3 of 5CMS staffing star rating
- 4 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (734) 241-9533
- Last standard health inspection
- March 19, 2026 (7 months ago)
- Certified beds
- 122
- Residents per day, on average
- 80.6
- Ownership type
- Non profit - Corporation
- Legal business name
- Lutheran Homes of Michigan, INC
- Chain
- Not listed by CMS
- Takes part in
- Medicare and Medicaid
Fewer health citations than the Michigan average (6 vs 32).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS overall star rating changed from 4 of 5 to 5 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 3 of 5.
CMS update of July 29, 2026
Star rating
The CMS overall star rating changed from 5 of 5 to 4 of 5.
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
Staffing
Total nurse staffing reported to CMS went from 3.7 to 2.1 hours per resident per day.
CMS update of April 29, 2026
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
Staffing
Total nurse staffing reported to CMS went from 4.2 to 3.7 hours per resident per day.
2 citations
Health inspection on March 19, 2026
CMS lists this as a standard inspection.
Citation F0550. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on April 21, 2026.
Citation F0887. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on April 21, 2026.
15 citations
Fire safety inspection on March 19, 2026
CMS lists this as a standard inspection.
Citation E0004. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop and maintain an Emergency Preparedness Program (EP).
CMS lists it as corrected on April 21, 2026.
CMS has cited this home for E0004 2 times since 2023.
Citation E0018. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish procedures for tracking staff and patients during an emergency.
CMS lists it as corrected on April 21, 2026.
Citation E0024. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish policies and procedures for volunteers.
CMS lists it as corrected on April 21, 2026.
Citation E0026. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish roles under a Waiver declared by secretary.
CMS lists it as corrected on April 21, 2026.
Citation E0036. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish emergency prep training and testing.
CMS lists it as corrected on April 21, 2026.
Citation E0039. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on April 21, 2026.
Citation K0324. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on April 21, 2026.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on April 21, 2026.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on April 21, 2026.
CMS has cited this home for K0353 3 times since 2023.
Citation K0362. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
CMS lists it as corrected on April 21, 2026.
Citation K0363. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on April 21, 2026.
CMS has cited this home for K0363 2 times since 2025.
Citation K0521. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on April 21, 2026.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on April 21, 2026.
Citation K0222. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 21, 2026.
CMS has cited this home for K0222 2 times since 2025.
Citation K0511. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on April 21, 2026.
CMS has cited this home for K0511 2 times since 2023.
CMS update of February 25, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
1 citation
Health inspection on November 21, 2025
CMS lists this as a complaint inspection.
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on December 1, 2025.
CMS update of November 20, 2025
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
Name
CMS lists a new name for this home. It was WELLSPRING LUTHERAN NURSING AND REHAB SERVICES.
CMS update of July 30, 2025
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
CMS update of April 30, 2025
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
CMS update of February 26, 2025
Ownership
CMS no longer lists a chain for this home.
1 citation
Health inspection on January 14, 2025
CMS lists this as a complaint inspection.
Citation F0583. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep residents' personal and medical records private and confidential.
CMS lists it as corrected on February 21, 2025.
11 citations
Fire safety inspection on January 14, 2025
CMS lists this as a standard inspection.
Citation K0351. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install an approved automatic sprinkler system.
CMS lists it as corrected on April 30, 2025.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on February 28, 2025.
Citation K0920. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on February 28, 2025.
Citation K0222. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on February 28, 2025.
Citation K0223. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
CMS lists it as corrected on February 28, 2025.
Citation K0321. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on February 28, 2025.
Citation K0342. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
CMS lists it as corrected on February 28, 2025.
Citation K0355. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on February 28, 2025.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on February 28, 2025.
Citation K0914. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
CMS lists it as corrected on February 28, 2025.
Citation K0923. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on February 28, 2025.
CMS update of January 31, 2024
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
2 citations
Health inspection on December 20, 2023
CMS lists this as a standard inspection.
Citation F0644. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
CMS lists it as corrected on January 17, 2024.
Citation F0947. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
CMS lists it as corrected on January 17, 2024.
10 citations
Fire safety inspection on December 20, 2023
CMS lists this as a standard inspection.
Citation E0004. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop and maintain an Emergency Preparedness Program (EP).
CMS lists it as corrected on January 17, 2024.
Citation E0029. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop a communication plan.
CMS lists it as corrected on January 17, 2024.
Citation K0291. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on January 17, 2024.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on January 17, 2024.
Citation K0711. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide a written emergency evacuation plan.
CMS lists it as corrected on January 17, 2024.
Citation K0753. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have restrictions on the use of highly flammable decorations.
CMS lists it as corrected on January 17, 2024.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on January 17, 2024.
Citation K0211. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on December 15, 2023.
Citation K0372. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on January 17, 2024.
Citation K0511. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on January 17, 2024.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- CASSIDY, BRUCEOperational/managerial control · not applicable · since 01/01/2023
- GEHM, DAVIDOperational/managerial control · not applicable · since 01/15/1994
- KALBFLEISCH, TIMOTHYOperational/managerial control · not applicable · since 08/01/2019
- PICCININNI, JUDYOperational/managerial control · not applicable · since 02/01/2024
- TERRY, STEPHENOperational/managerial control · not applicable · since 09/22/2025
Questions
When was Wellspring Lutheran Nursing and Rehab Services last inspected?
CMS lists March 19, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Wellspring Lutheran Nursing and Rehab Services have?
CMS lists 6 health citations since December 20, 2023. CMS also calls these deficiencies.
Has Wellspring Lutheran Nursing and Rehab Services been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Wellspring Lutheran Nursing and Rehab Services?
Its CMS overall star rating is 5 of 5.
Is Wellspring Lutheran Nursing and Rehab Services a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.