Skip to main content
ReadyRule homepageReadyRule

Public Record

Wellspring Lutheran Nursing and Rehab Services

Nursing HomeMonroe, MICMS 235274
35 citations on record

From CMS

Facility profile

CMS overall rating
5 / 5

*CMS Five-Star

Certified beds
122

*CMS

Avg. residents per day
74.7

*CMS

Inspection record

On record from CMS

Citations on record
35

*CMS

Inspections on file
6

*CMS

Last inspection
2025-11-21

*CMS

Citations

35 citations on record

Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0658Generalpotential for harm

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

  • 0914Generalpotential for harm

    Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

  • 0222Generalpotential for harm

    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.

  • 0223Generalpotential for harm

    Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

  • 0321Generalpotential for harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  • 0342Generalpotential for harm

    Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.

  • 0351Generalpotential for harm

    Install an approved automatic sprinkler system.

  • 0353Generalpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0355Generalpotential for harm

    Properly select, install, inspect, or maintain portable fire extinguishes.

  • 0363Generalpotential for harm

    Install corridor and hallway doors that block smoke.

  • 0920Generalpotential for harm

    Ensure proper usage of power strips and extension cords.

  • 0923Generalpotential for harm

    Have proper medical gas storage and administration areas.

  • 0583Generalpotential for harm

    Keep residents' personal and medical records private and confidential.

  • 0291Generalpotential for harm

    Install emergency lighting that can last at least 1 1/2 hours.

  • 0353Generalpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0372Generalpotential for harm

    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  • 0511Generalpotential for harm

    Have properly installed electrical wiring and gas equipment.

  • 0711Generalpotential for harm

    Provide a written emergency evacuation plan.

  • 0753Generalpotential for harm

    Have restrictions on the use of highly flammable decorations.

  • 0029Generalpotential for harm

    Develop a communication plan.

  • 0918Generalpotential for harm

    Have generator or other power source capable of supplying service within 10 seconds.

  • 0644Generalpotential for harm

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

  • 0004Generalpotential for harm

    Develop and maintain an Emergency Preparedness Program (EP).

  • 0947Generalpotential for harm

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

  • 0211Generalpotential for harm

    Keep aisles, corridors, and exits free of obstruction in case of emergency.

  • 0712Generalpotential for harm

    Have simulated fire drills held at unexpected times.

  • 0920Generalpotential for harm

    Ensure proper usage of power strips and extension cords.

  • 0211Generalpotential for harm

    Keep aisles, corridors, and exits free of obstruction in case of emergency.

  • 0271Generalpotential for harm

    Have exits that are accessible at all times.

  • 0321Generalpotential for harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  • 0324Generalpotential for harm

    Provide properly protected cooking facilities.

  • 0345Generalpotential for harm

    Have approved installation, maintenance and testing program for fire alarm systems.

  • 0351Generalpotential for harm

    Install an approved automatic sprinkler system.

  • 0711Generalpotential for harm

    Provide a written emergency evacuation plan.

  • 0912Generalpotential for harm

    Have power receptacles that are properly grounded.

Inspection history

Every health inspection on record

Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.

FAQ

Questions and answers

What is Wellspring Lutheran Nursing and Rehab Services?
Wellspring Lutheran Nursing and Rehab Services is a Medicare- and Medicaid-certified nursing home in Monroe, MI, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 235274.
What is the CMS rating for Wellspring Lutheran Nursing and Rehab Services?
Wellspring Lutheran Nursing and Rehab Services has a CMS overall rating of 5 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
How many beds does Wellspring Lutheran Nursing and Rehab Services have?
Wellspring Lutheran Nursing and Rehab Services is certified for 122 beds. It serves an average of 74.7 residents per day.
How many citations does Wellspring Lutheran Nursing and Rehab Services have?
Wellspring Lutheran Nursing and Rehab Services has 35 citations on record from CMS health inspections, each tied to a federal deficiency tag.
When was Wellspring Lutheran Nursing and Rehab Services last inspected?
Wellspring Lutheran Nursing and Rehab Services was last inspected on November 21, 2025. CMS surveys nursing homes about once a year and after complaints.
What can I do if I have concerns about care at this facility?
Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.

*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.

/nursing-home/235274-wellspring-lutheran-nursing-and-rehab-services