Wellspring Lutheran Services

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

57.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 137 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 34.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 75 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.42 therapist hours per resident per day in 2026Q1 — more than 72% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 22% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 83 beds and averages 49.2 residents a day — about 59% occupied, or roughly 34 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.96 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.66 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.66 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.69 hrs/resident/day on weekends vs 4.07 on weekdays — 9% thinner on weekends. RN hours go from 0.75 to 0.46 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 48% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.

• Potential for harm · E2025-08-14 · tag F0578 — failed to honor advance directives / code status — pattern
  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Code Status was accurately assessed, documented and accessible in the medical record and plan of care for 4 residents (#9, #27, #28, #45 ) , resulting in the potential for the resident's lack of informed knowledge related to options for code status and miscommunication of code status which could lead to a lack of appropriate interventions for care. Resident #27 (R27) A record review of the Face Sheet and Minimum Data Set/MDS assessment indicated R27 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Unspecified Dementia, severe with other behavioral disturbance, Delusional Disorders, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, and Obstructive and Reflux Uropathy in addition to other diagnoses. A review of R27's assessment for Code status preferences titled, Advance Care Planning Form, revealed No was checked for Cardiopulmonary Resuscitation (CPR). Yes was marked for Artificial Nutrition…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-08-14 · tag F0759 — failed to keep medication error rate low — pattern
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a medication administration error rate of less than 5% when nine (9) medication errors were observed from a total of 25 opportunities for three residents (Resident #1, Resident #29 and Resident # 57) of five (5) residents observed for medication administration, resulting in an error rate of 36.0%. Findings Include: On 8/13/25 at 7:45 AM, Registered Nurse K was observed administering the medication at the [NAME] End Nurse's Station.RN 'K' gave R57 the Chewable Aspirin (ASA) tablet, which was placed with three other oral medications in one medicine cup. R# was observed taking all her medications whole at once and swallowing them after a small cup of water. Resident #57 (R57) A review of R57 Face Sheet revealed R57 was admitted at the facility on 8/9/ 25 with the following diagnoses: Osteoporosis, Venous insufficiency, and pathological Fracture in addition to other diagnoses.On 08/13/2025 at 7:45 AM, RN K was observed preparing R57's…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-08-14 · tag F0761 — failed to label and store drugs safely — pattern
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to store and handle medications in accordance with acceptable pharmaceutical standards of practice and ensure medication refrigerator temperatures outside of acceptable parameters were addressed, resulting in the potential for contamination of medications, a lack of therapeutic benefits necessary to promote healing for residents, increased potential for adverse effects. Findings include:On 8/14/25, starting at 8:20 AM, two medication carts were checked and observed, and the narcotics were reconciled. Two medication rooms were inspected, which included the refrigerator that holds the medication requiring refrigeration per the manufacturer's recommendation, such as reconstituted IV solution, insulin, vaccinations, and suppositories.During Medication Storage inspection, Nurse L on 8/14/25 10:45 AM opened the refrigerator in the [NAME] Wing Medication Room, and the inside thermometer read 50 degrees Fahrenheit. Although Nurse L argued that it was 48 degrees a second ago, she reread and agreed it held at 50 degrees.…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-08-14 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
  Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the appropriate backflow prevention was installed on cross connections. This deficient practice increases the likelihood of contamination of the water supply due to a backflow event, potentially affecting all residents, staff, and visitors who consume water at the facility. Findings include: On 08/12/2025 at approximately 9:30AM observed a hose with an attached spray nozzle connected to the water line downstream of an atmospheric vacuum breaker (AVB) located in the kitchen near the dishwasher. On 08/12/2025 at approximately 1:30PM during the environmental tour of the facility, an interview was conducted with the Director of Maintenance I on the cross connection related to the attached spray nozzle in the kitchen. The Director of Maintenance I was knowledgeable about the cross connection and removed the hose with the attached spray nozzle. On 08/12/2025 at approximately 1:45 PM observed chemical feed dispenser supplied by the utility…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-14 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure choices on meals are honored and prompt response to call lights for Resident #6 (R6), maintain the resident's confidentiality of an emergency plan for Resident #49 (R49) and provide resident's privacy during medication administration for Resident #29 (R29) for three residents (R6, R49 and R29) of three reviewed for dignity. Findings include:Resident #49 (R49):A review of the Electronic Medical Record (EMR) conducted on August 12, 2025, at 3:00 PM revealed that R49 was admitted to the facility on [DATE]. She is currently under hospice care. Her Brief Interview of Mental Status (BIMS) Score dated July 2, 2025, was undetermined. The score box was left blank. However, staff indicated in the assessment that R49 had a memory problem (both short-term and long-term memory), a problem with recalling (names, faces, seasons, and locations), and her cognitive skills for daily decision making, according to the facility, were severely impaired.…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-14 · tag F0658 — failed to meet professional standards of care — isolated
  Ensure services provided by the nursing facility meet professional standards of quality.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to 1.) evaluate and contact provider with abnormal laboratory findings prior to medication administration of Potassium supplement for Resident #52; 2.)provide assessment, monitoring, and treatment for a Resident with a PEG (percutaneous endoscopic gastrostomy) tube for Resident #27; and 3.) follow standards of practice for Midline intravenous flushing for Resident #29, of three reviewed for standard of practice.Resident #27 (R27) On [DATE] at 9:00 AM, a record review of the R27's Face Sheet and Minimum Data Set/MDS assessment indicated R27 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Unspecified Dementia, severe with other behavioral disturbance, Delusional Disorders, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, and Obstructive and Reflux Uropathy in addition to other diagnoses. R27's Brief Interview of Mental Status (BIMS) Score on [DATE] was 13/15. A score of 13 indicates…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-14 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a timely response to a change in condition for Resident #65; assess/respond to abnormal vital signs for Resident #52 and Resident #65; and ensure antibiotics were ordered and administered timely for Resident #63, for three residents (#52, #63 and #65) of four residents reviewed for a change in condition and antibiotic administration, resulting in a delay in treatment, increased abdominal pain and hospitalization for Resident #65, and a delay of antibiotics for Resident #63 with the potential for continued infection and delay in assessment/treatment of abnormal vital signs for Resident #52.Resident #52: A review of Resident #52's medical record revealed an admission into the facility on [DATE] and date of discharge [DATE] with diagnoses that included fracture of right humerus and greater trochanter of right femur, chronic kidney disease, heart failure, atrial fibrillation, and hyperkalemia (a medical condition where the body has high…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to provide adequate supervision and safely assist residents to prevent falls with injury for one resident (Resident #7) of four residents reviewed for accidents with falls, resulting in R7 falling from their wheelchair, requiring a hospital emergency room visit with laceration repairs.Findings include: Resident #7 (R7):Record review of Resident 7's (R7) quarterly Minimum Data Set /MDS revealed Brief Interview of Mental Status (BIMS) of 99, defined as severely cognitively impaired never/rarely made decisions. R7 was assessed as dependent in all activities of daily living (ADL) and transfers. Medical diagnoses included: End Stage Renal Disease, Cardiac Defibrillator, Anxiety Disorder, Major Depressive Disorder, Dementia with Behavioral Disturbance. R7 was in long term care/LTC at the facility and was admitted to their hospice care on 7/23/2025.On 8/12/2025 at 2:50 PM, an observation was made of R7 who was in the hallway by the west hall nursing station and sitting in a Geri chair (a large reclining mobile chair)…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-14 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide necessary management and care of an indwelling urinary catheter drainage bag to ensure it was not sitting on the floor for 1 resident (#62), resulting in the potential for complications including infection, obstruction of urine and a decline in condition. Urinary Catheter Resident #62 On 8/12/2025 at 11:41 AM, Resident #62 was observed lying in bed sleeping. His bed was in a very low position and the urinary catheter bag was in a white cloth bag on the floor; it was not hanging freely to drain and was pushed against the floor. A record review of the Face sheet and electronic medical record indicated Resident #62 was admitted to the facility on [DATE] with diagnoses: Parkinson's disease, stage 4 sacral pressure ulcer, osteomyelitis of vertebra, sacral and coccygeal region, neuromuscular dysfunction of the bladder, right lower leg contracture, diarrhea, and aphasia. The resident was receiving Hospice services. On 8/13/2025 at 10:35…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-14 · tag F0694 — isolated
  Provide for the safe, appropriate administration of IV fluids for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to ensure assessment of measurements for a midline catheter was completed and the midline catheter was flushed appropriately for one Resident #29, of one reviewed for intravenous catheters.A review of Resident #29's medical record revealed an admission into the facility on 7/23/25 with diagnoses that included acquired absence of right toe(s), diabetes with foot ulcer, ulcer of left heel and midfoot, and acute osteomyelitis, left ankle and foot. Further review of the medical record revealed the Resident had a Midline catheter that was used to administer intravenous (IV) antibiotics. On 8/12/25 at 12:45 PM, Resident #29 was observed in their room, laying on the bed. The Resident was interviewed, answered questions and engaged in conversation. The Resident was asked about receiving antibiotics. The Resident reported getting IV antibiotics through a midline catheter. An observation was made of a Midline catheter dressing to the right arm. The Midline catheter had an external catheter, and the insertion site was…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

CMS files one row per role, so the 8 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $451K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in MI