WELLSPRING LUTHERAN NURSING AND REHAB SERVICES

Nursing Home Inspector

1236 S MONROE ST
MONROE, MI 48161
Monroe County
Phone: 734-241-9533
Provider Number: 235274
Last Inspection: 05/25/2017

About the Nursing Home

Number of Beds: 122
Number of Residents: 112
Beds Available: 10
Percent Occupancy: 92%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: Non profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

28

Facility
25

County
31

MI
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

28

2017
0

2016
12

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

5/25/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep residents' personal and medical records private and confidential. Isolated : Minimal 3 6/15/2017
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 6/15/2017
 
Failed To: Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. Pattern : Minimal 4 6/15/2017
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Pattern : Minimal 4 6/15/2017
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 6/15/2017
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 6/15/2017
 
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated : Minimal 3 6/15/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Actual 4 6/15/2017
 

9/18/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Widespread : Minimal 5 10/3/2015
 
Failed To: Have enough outside ventilation via a window or mechanical ventilation, or both. Pattern : Minimal 4 10/3/2015
 
Failed To: Allow residents to self-administer drugs if determined safe. Isolated : Minimal 3 10/3/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

No Complaint Deficiencies Reported

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg MI State Avg
Number of Residents 112 83.29 85.64
Registered Nurses 0.58 0.79 0.89
Licensed Practical / Vocational Nurses 0.93 0.82 0.84
Certified Nursing Assistants 3.08 2.21 2.54
Total Staff Hours 4.60 3.82 4.27

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% MI State Avg%
of high risk long-stay residents with pressure ulcers 3 4 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 100 99 92
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 99 98 92
of long-stay residents experiencing one or more falls with major injury 5 3 3
of long-stay residents who have depressive symptoms 0 3 2
of long-stay residents who lose too much weight 3 6 7
of long-stay residents who received an antianxiety or hypnotic medication 27 25 22
of long-stay residents who received an antipsychotic medication 11 9 12
of long-stay residents who self-report moderate to severe pain 8 8 6
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 17 14 17
of long-stay residents whose need for help with daily activities has increased 12 12 14
of long-stay residents with a catheter inserted and left in their bladder 1 1 2
of long-stay residents with a urinary tract infection 5 4 3
of low risk long-stay residents who lose control of their bowels or bladder 49 47 50
of short-stay residents assessed and appropriately given the pneumococcal vaccine 99 93 80
of short-stay residents who had an outpatient emergency department visit 9 10 11
of short-stay residents who made improvements in function 88 78 71
of short-stay residents who newly received an antipsychotic medication 1 2 1
of short-stay residents who self-report moderate to severe pain 20 18 16
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 94 90 79
of short-stay residents who were rehospitalized after a nursing home admission 22 24 21
of short-stay residents who were successfully discharged to the community 72 61 56
of short-stay residents with pressure ulcers that are new or worsened 1 0 0