Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wellspring Lutheran Nursing And Rehab Services during CMS and state inspections, most recent first.
A facility discontinued brief liners for cost reasons, leaving several cognitively intact residents without incontinence protection they had been using as part of their care. Residents with diagnoses including OAB, urinary retention, CKD, Parkinson’s disease, and mobility-related incontinence reported embarrassment, humiliation, stress, and loss of independence after being told the liners would only be available with a doctor’s order or self-purchase, even though some already had orders. Surveyors also found no liners in the supply closet, and the NHA stated the issue had not been addressed in QA/QAPI.
The facility failed to educate and offer the COVID-19 vaccine to four residents reviewed for infection control. Record review showed residents with CKD, hemiplegia, COPD, and HF were not provided COVID-19 education and were not offered the vaccine in 2025. The ICP confirmed the facility did not consistently educate residents on COVID-19 vaccination and boosters or offer the vaccine per policy, and the DON stated residents should have been educated and offered the vaccine.
An LPN attempted to give a resident four capsules of Budesonide instead of the ordered two after misunderstanding a medication change and not recognizing that the prior order had been discontinued. The resident questioned the dose, and the LPN admitted the error and that no progress note was completed. Records showed the resident had intact cognition and the medication order had changed from COPD to bowel use.
A deficiency was cited due to the facility not being fully protected by an approved automatic sprinkler system as required by NFPA 13 and related Life Safety Code standards. The report references a temporary waiver for the incomplete installation or coverage of the sprinkler system.
A staff member recorded and shared videos of two cognitively impaired residents without consent, including inappropriate captions, using social media private messaging. This action violated facility policy prohibiting photographing residents and resulted in a breach of privacy and confidentiality.
Failure to Provide Ordered Incontinence Liners
Penalty
Summary
The facility failed to ensure the highest level of incontinence functioning was maintained for four residents who were reviewed for quality of life, after an administrative decision was made to discontinue brief liners because of cost. Residents reported that the change left them without the incontinence protection they had been using, and three residents stated during a Resident Council meeting that they felt stress, anxiety, humiliation, dehumanization, and embarrassment because of the loss of the liners. R4, who had a BIMS score of 15 and diagnoses including retention of urine, congenital malformation of kidney, myeloproliferative disease, and lymphoma, reported being upset after being told the brief inserts were discontinued. R4 stated that a St. Patrick’s Day dress was soiled during an activity because the liners were no longer provided, and described the experience as disappointing, saddening, stressful, humiliating, and embarrassing. R4’s care plan documented urge/OAB bladder incontinence and bowel incontinence, with an intervention stating that pull-up briefs were to be worn at all times and incontinence care provided as needed. R62, who was cognitively intact with diagnoses including overactive bladder, diabetes, kidney disease, and Parkinson’s disease, reported that the facility told residents the brief inserts were no longer being provided due to expense and that they would only be available with a doctor’s order or if purchased privately. R62 stated that a doctor’s order had been obtained, but the inserts still were not being provided, and reported embarrassment, stress, and frustration related to soiling clothes during activities. R64, also cognitively intact, reported that discontinuing the brief liners reduced his independence because he now required staff assistance for frequent brief changes, and he described embarrassment and humiliation after a urinary accident in the dining room. His care plan documented renal insufficiency, chronic kidney disease, MDROs in urine, urge/OAB bladder incontinence, bowel incontinence, and that he wore pull-up briefs at all times. R81, who was cognitively intact with diagnoses including chronic pain, peripheral vascular disease, and polyneuropathy, reported that the liners were used to prevent accidents and help manage urinary leakage when staff were too busy to assist. R81 stated that the facility was no longer ordering the liners unless residents paid out of pocket, despite a physician’s order for liners to be used in the brief as needed three times a day. Survey observation found no liners in the 200-unit linen/supply closet, only incontinence briefs. The Nursing Home Administrator stated that the decision to discontinue the liners was made in February 2026 due to cost, that residents with a doctor’s order and medical diagnosis should continue to receive them, and that the issue had not been addressed in QA/QAPI.
Failure to Educate and Offer COVID-19 Vaccine
Penalty
Summary
The facility failed to educate and offer the COVID-19 vaccine to four residents who were reviewed for infection control: R2, R16, R22, and R72. Record review showed R2 had chronic kidney disease, R16 had hemiplegia, R22 had COPD, and R72 had heart failure. For each of these residents, the facility did not provide COVID-19 education and did not offer the vaccine in 2025. During an interview on 3/19/26, the Infection Control Preventionist confirmed the facility did not ensure residents were consistently educated regarding COVID-19 vaccination and boosters and did not ensure the vaccine was offered in accordance with facility policy. The DON also stated that the facility should have ensured residents were educated and offered the COVID-19 vaccine. The facility policy dated 8/25 stated that each resident should be offered any recommended COVID-19 vaccines or boosters they are eligible for at admission and ongoing as indicated per CDC guidelines.
Medication Administration Error With Budesonide
Penalty
Summary
The nursing facility failed to ensure nursing services were provided in accordance with professional standards of quality for one resident, R401, during medication administration. R401, who had diagnoses including gastroenteritis and colitis, major depressive disorder, atrial fibrillation, and dementia, stated that an LPN gave her four pills of Budesonide when she usually takes two, and that the nurse acknowledged there should only have been two pills. R401 also said the medication mix-up concerned her because there may come a time when she does not remember what medications and how many she is supposed to be taking. The LPN stated she had received report that there was a change in R401’s medication and believed it was a new medication being added. She said she gave four pills in the medication cup because she was not familiar with the computer system and did not know the first order had been discontinued. The LPN admitted she did not complete a progress note about the incident. Record review showed Budesonide ER 3 mg, 2 capsules daily for COPD had been discontinued on 8/26/2025, and a new order for Budesonide ER 3 mg, 2 capsules daily for bowels started on 8/27/2025. The facility’s grievance record documented that R401’s representative reported the attempted administration of four capsules instead of the prescribed two capsules, and the MDS showed R401 had a BIMS score of 15 out of 15.
Deficiency in Sprinkler System Installation
Penalty
Summary
A deficiency was identified regarding the installation of an approved automatic sprinkler system throughout the facility, as required by NFPA 13 and referenced Life Safety Code sections. The report notes that the facility did not meet the requirement for full sprinkler protection in accordance with the specified standards for nursing homes and hospitals. The deficiency is documented with reference to a temporary waiver, indicating that the required sprinkler system installation or coverage was not fully in place at the time of the survey. No specific details about individual patients, their medical history, or their condition at the time of the deficiency are mentioned in the report.
Failure to Protect Resident Privacy Through Unauthorized Video Recording
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of two residents' personal and medical information. A staff member recorded videos of two residents, both of whom had severe cognitive impairment and required substantial to maximal assistance with activities of daily living. The videos were created without the residents' consent and included captions referencing the residents in a manner that was inappropriate and disclosed personal information. The videos were then sent to a coworker via private messaging on social media platforms such as Instagram and Snapchat. The facility's own policy explicitly prohibited photographing residents with any device and stated that such actions would be subject to disciplinary action. Interviews with facility staff, including the social worker and nursing home administrator, confirmed that the video recordings were considered an invasion of the residents' privacy. The residents involved were unable to recall or respond to the events due to their cognitive impairments, further underscoring their vulnerability at the time of the incident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Monroe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ihm Senior Living Community | 1 mi | ★★★★★ | 0 | 0 |
| Medilodge Of Monroe | 1.6 mi | ★★★★★ | 0 | 0 |
| Seacrest Rehabilitation And Nursing Center | 2.1 mi | ★★★★★ | 13 | 0 |
| Monroe Springs Skilled Nursing And Rehab | 2.2 mi | ★★★★★ | 8 | 0 |
| Fountain View Of Monroe | 2.7 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.