01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-03-19 | 3 | 2026-03-19 | 15 |
| Cycle 2 | 2025-01-14 | 1 | 2025-01-14 | 11 |
| Cycle 3 | 2023-12-20 | 2 | 2023-12-20 | 10 |
CMS CCN 2352742026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Wellspring Lutheran Nursing And Rehab Services
1236 S Monroe St · Monroe, MI 48161 · Monroe County
Certified beds122CMS provider file
Recent citation rows42current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
42 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 5 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-03-19 · FIREE0004Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Develop and maintain an Emergency Preparedness Program (EP).
Correction field: Deficient, Provider has date of correction · 2026-04-212026-03-19 · FIREE0018Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish procedures for tracking staff and patients during an emergency.
Correction field: Deficient, Provider has date of correction · 2026-04-212026-03-19 · FIREE0024Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish policies and procedures for volunteers.
Correction field: Deficient, Provider has date of correction · 2026-04-212026-03-19 · FIREE0026Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish roles under a Waiver declared by secretary.
Correction field: Deficient, Provider has date of correction · 2026-04-212026-03-19 · FIREE0036Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish emergency prep training and testing.
Correction field: Deficient, Provider has date of correction · 2026-04-212026-03-19 · FIREE0039Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Correction field: Deficient, Provider has date of correction · 2026-04-212026-03-19 · HEALTHF0550Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2026-04-212026-03-19 · HEALTHF0887Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2026-04-212026-03-19 · FIREK0222Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2026-04-212026-03-19 · FIREK0324Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2026-04-212026-03-19 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2026-04-212026-03-19 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2026-04-212026-03-19 · FIREK0362Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Correction field: Deficient, Provider has date of correction · 2026-04-212026-03-19 · FIREK0363Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has date of correction · 2026-04-212026-03-19 · FIREK0511Severity D · isolated; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2026-04-212026-03-19 · FIREK0521Severity F · widespread; potential for more than minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has date of correction · 2026-04-212026-03-19 · FIREK0712Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2026-04-212025-11-21 · HEALTHF0658Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Correction field: Deficient, Provider has date of correction · 2025-12-01 · complaint2025-01-14 · HEALTHF0583Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
Correction field: Deficient, Provider has date of correction · 2025-02-21 · complaint2025-01-14 · FIREK0222Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-02-282025-01-14 · FIREK0223Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Correction field: Deficient, Provider has date of correction · 2025-02-282025-01-14 · FIREK0321Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2025-02-282025-01-14 · FIREK0342Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Correction field: Deficient, Provider has date of correction · 2025-02-282025-01-14 · FIREK0351Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Install an approved automatic sprinkler system.
Correction field: Waiver has been granted · 2025-04-3003 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- BENDER, PETERIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 06/18/2012
- BENKO, AMYIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 04/04/2016
- CUSHWAY, RITCHIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 05/09/2013
- GEHM, DAVIDIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/15/1994
- LOGAN, ANDREAIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/01/2025
- NYQUIST, PAULIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/27/2014
- SCHOENOW, CARLIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 11/24/2014
- STORCK, KARENIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 07/10/2018
- BENDER, PETERIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 06/18/2012
- BENKO, AMYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 04/04/2016
- CUSHWAY, RITCHIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 05/09/2013
- GEHM, DAVIDIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/15/1994
- LOGAN, ANDREAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2025
- NYQUIST, PAULIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/27/2014
- SCHOENOW, CARLIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 11/24/2014
- STORCK, KARENIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/10/2018
- GEHM, DAVIDIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/15/1994
- KALBFLEISCH, TIMOTHYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 08/01/2019
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours2.10per resident day
RN hours0.32per resident day
Weekend nurse hours1.75per resident day
Staff turnover53.3%CMS reported field
06 / LOCAL RECORDS
Open the Monroe ledger →Other published facilities nearby
Fountain View Of Monroe119 beds · CMS overall 5/510 citation rowsIhm Senior Living Community58 beds · CMS overall 5/512 citation rowsMedilodge Of Monroe103 beds · CMS overall 5/513 citation rowsMonroe Springs Skilled Nursing And Rehab89 beds · CMS overall 4/519 citation rowsSeacrest Rehabilitation And Nursing Center131 beds · CMS overall 4/541 citation rows