Monroe Springs Skilled Nursing and Rehab
700 Stewart Rd, Monroe, MI 48161 · Monroe County · (734) 240-1820
89 certified beds, about 82 residents a day · For profit - Individual · Medicare and Medicaid since 1992
CMS Care Compare ratings, data as of September 1, 2026 · CCN 235520 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on December 3, 2025, inspectors cited 3 health deficiencies (the Michigan average is 9.9, the national average 9.2).
Of 9 health citations since November 2023, 1 was rated as actual harm or immediate jeopardy to residents.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 3.84 hours per resident per day, against 3.99 across Michigan and 3.86 nationally. Registered nurses accounted for 0.36 of those hours.
28.0% of nursing staff left within the year CMS measured (Michigan average 44.1%).
CMS links it to Avon Healthcare, an affiliated group of 9 nursing homes.
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 9 health citations on file.
June 24, 2026Complaint inspection · 4 citations
- G Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteThis citation pertains to intake 3037808. Based on interview and record review the facility failed to provide adequate supervision from two staff members during a transfer with a mechanical lift for one (R507) of five residents reviewed for accident hazards/safety resulting in R507 falling off the lift during transfer, hitting their head, and requiring five staples for wound closure.
- D Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteThis citation pertains to intake 3018035. Based on interview and record review the facility failed to notify the physician of missing medications for one (R506) of four residents reviewed for medication administration resulting in the physician being unaware that R506 missed two consecutive medication doses for a respiratory inhaler and an antibiotic.
- D Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteThis citation pertains to intake 3037808. Based on interview and record review the facility failed to report an injury of unknown origin for one (R507) of four residents reviewed for abuse.
- D Assist a resident in gaining access to vision and hearing services.
Inspectors wroteThis citation pertains to intake 3018035. Based on observation, interview, and record review, the facility failed to make an ophthalmology appointment as ordered by the physician for one (R505) of three residents reviewed for the coordination of outside physician appointments resulting in the delay of ophthalmology services for R505.
December 3, 2025Standard inspection, Complaint inspection · 3 citations
- E Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to properly date-label stored food and remove expired food in resident refrigerators affecting all the residents who consumed food from the unit refrigerators resulting in unidentifiable resident food items, expired food items, and the potential for food-borne illness.
- D Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the misappropriation of one resident's (R22) property from four residents reviewed for abuse resulting in 26 tablets of R22's narcotic pain medication (oxycodone 10-325 milligram (mg)) missing and unaccounted for.
- D Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide appropriate PEG tube care (a tube placed directly into the stomach through an abdominal wall incision for the administration of food, fluids, and medication) for one (R47) resident reviewed for tube feeding resulting in a compromised PEG tube with no cap, difficulty administering medications, and the potential for infection.
October 24, 2024Standard inspection · 0 citations
December 12, 2023Complaint inspection · 1 citation
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteThis citation pertains to intake MI00141226. Based on interview and record review the facility failed to properly secure a resident in a wheelchair before transportation for one resident (R901) out of three residents reviewed for safety, resulting in R901's wheelchair tipping backward and the potential for injury.
November 20, 2023Standard inspection · 1 citation
- F Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting 79 residents who receive meal services (1 nothing by mouth residents, or NPO) out of the facility's total census of 80 residents.
Fire safety inspections
10 fire safety citations on file: 1 on December 3, 2025, 5 on October 24, 2024, 4 on November 20, 2023.
Every fire safety citation10 citations
- F Have generator or other power source capable of supplying service within 10 seconds.
- F Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- F Inspect, test, and maintain automatic sprinkler systems.
- F Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- F Have restrictions on the use of highly flammable decorations.
- D Have power receptacles that are properly grounded.
- E Have stairways and smokeproof enclosures used as exits that meet safety requirements.
- E Inspect, test, and maintain automatic sprinkler systems.
- E Have properly installed electrical wiring and gas equipment.
- D Ensure proper usage of power strips and extension cords.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Michigan | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.84 | 3.99 | 3.86 |
| Registered nurses | 0.36 | 0.78 | 0.69 |
| All nursing staff on weekends | 3.53 | 3.50 | 3.42 |
| Nurse aides | 2.06 | ||
| Licensed practical nurses | 1.41 | ||
| Nursing staff turnover (share who left in a year) | 28.0% | 44.1% | 45.8% |
| Registered nurse turnover | 22.2% | 39.2% | 42.9% |
| Administrators who left | 0 |
CMS expects 4.09 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.96 on weekdays and 3.53 on weekends, 11% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.5% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.82 in April to June 2025 to 3.84 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.84 | 0.36 | 3.96 | 3.53 | 0.5% | 0 of 90 | 82 |
| Oct to Dec 2025 | 3.96 | 0.45 | 4.10 | 3.60 | 0.4% | 1 of 92 | 80 |
| Jul to Sep 2025 | 3.78 | 0.41 | 3.93 | 3.41 | 0.0% | 0 of 92 | 84 |
| Apr to Jun 2025 | 3.82 | 0.39 | 3.97 | 3.47 | 0.0% | 0 of 91 | 81 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Michigan, Jan to Mar 2026 | 3.95 | 0.70 | 4.14 | 3.45 | 3.3% | 0.4% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Michigan | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 11.1 | 10.8 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 1.3 | 0.8 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.3 | 1.5 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 4.1 | 3.0 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 2.6 | 1.1 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 19.7 | 12.0 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 4.8 | 5.1 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 16.6 | 14.8 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 29.6 | 24.0 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 17.1 | 11.7 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.5 | 1.8 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 4.9 | 1.6 | 1.8 |
Owners and operators
Legal business name: MONROE SPRINGS OPERATING. CMS links this home to Avon Healthcare, a group of 9 nursing homes averaging 2.2 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Springs Bay Op Holdco LLC | 5% or greater direct ownership interest | Organization | 100% | 07/31/2023 |
| Gottlieb, Moshe | 5% or greater indirect ownership interest | Individual | 48% | 07/31/2023 |
| Freund, Eliyahu | Managing control - governing body | Individual | 07/31/2023 | |
| Freund, Eliyahu | Corporate officer | Individual | 07/31/2023 | |
| Bhurgri, Aamer | Operational/managerial control | Individual | 07/31/2023 | |
| Saba, Gail | Operational/managerial control | Individual | 07/31/2023 | |
| Wood, Krysten | Operational/managerial control | Individual | 07/31/2023 | |
| Avon Springs Bay Management LLC | Adp of the SNF | Organization | 01/22/2025 | |
| Monroe Springs Property LLC | Adp of the SNF | Organization | 01/22/2025 | |
| Bhurgri, Aamer | Adp of the SNF | Individual | 07/30/2025 | |
| Freund, Eliyahu | Adp of the SNF | Individual | 07/31/2023 | |
| Gottlieb, Moshe | Adp of the SNF | Individual | 07/31/2023 | |
| Wood, Krysten | Adp of the SNF | Individual | 07/31/2023 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 4 problems in this area, most recently on June 24, 2026: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
- How are allegations of abuse or neglect reported and investigated, and who tells the family?Inspectors cited 2 problems in this area, most recently on June 24, 2026: "Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities."
- Can we see a week of menus and the kitchen, and how are special diets handled?Inspectors cited 2 problems in this area, most recently on December 3, 2025: "Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 1 problem in this area, most recently on June 24, 2026: "Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident."
Other nursing homes nearby
- Fountain View of Monroe Monroe, 0.6 mi · 5 of 5 stars · 7 citations
- Seacrest Rehabilitation and Nursing Center Monroe, 0.6 mi · 4 of 5 stars · 15 citations
- Medilodge of Monroe Monroe, 1.1 mi · 5 of 5 stars · 6 citations
- Ihm Senior Living Community Monroe, 1.2 mi · 5 of 5 stars · 3 citations
- Wellspring Lutheran Nursing and Rehab Services Monroe, 2.2 mi · 4 of 5 stars · 6 citations
- Majestic Care of Point Place Toledo, 15 mi · 1 of 5 stars · 46 citations
- Aberdeen Rehabilitation and Skilled Nursing Center Trenton, 15.5 mi · 2 of 5 stars · 36 citations
- Applewood Nursing Center, Inc Woodhaven, 16 mi · 1 of 5 stars · 42 citations
Michigan contacts for a concern about a nursing home
These are the official offices in Michigan. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Michigan Department of Licensing and Regulatory Affairs, Bureau of Survey and Certification, Long Term Care Division, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Michigan Long Term Care Ombudsman Program, 1-866-485-9393. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: LARA State Licensing Search, where Michigan publishes its own records on licensed homes.
Common questions
- What is Monroe Springs Skilled Nursing and Rehab's Medicare star rating?
- CMS rates Monroe Springs Skilled Nursing and Rehab 4 out of 5 stars overall, with 4 for health inspections, 3 for staffing and 2 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Monroe Springs Skilled Nursing and Rehab get at its last inspection?
- 3 health deficiencies at the standard inspection on December 3, 2025. The Michigan average is 9.9.
- Has Monroe Springs Skilled Nursing and Rehab been fined?
- CMS lists no fines in the last three years.
- Does Monroe Springs Skilled Nursing and Rehab accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Monroe Springs Skilled Nursing and Rehab?
- CMS lists 13 owners and managers, and links the home to Avon Healthcare. Legal business name: MONROE SPRINGS OPERATING.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.