Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gladwin Nursing And Rehabilitation Community during CMS and state inspections, most recent first.
A resident with dementia and poor hand control suffered a second-degree burn after spilling hot coffee, due to the facility's failure to follow its hot liquid safety policy, inadequate assessment, and lack of supervision. Staff were unclear on temperature requirements and supervision protocols, and documentation was inconsistent, leading to the incident.
Two residents experienced significant incidents—one involving a physical assault resulting in facial injuries and another sustaining a second-degree burn from a hot liquid spill—that were not reported to the State Survey Agency or local law enforcement as required by facility policy. Leadership interviews confirmed awareness of the events and the lack of timely reporting, with no policy-based justification for the omissions.
A resident returned home from a respite stay with unexplained bruising and swelling. Despite reports from the resident's DPOA and hospice staff, the facility failed to initiate an investigation into the injuries, as required by their policy. Interviews revealed that the Administrator and DON did not take necessary actions to investigate the incident.
The facility failed to ensure call light systems were within reach for two residents, both with dementia and high fall risk. One resident was observed with the call light out of reach, leading to an unwitnessed fall, while another had the call light on the floor. Care plans required call lights to be accessible, but the facility lacked a specific policy on their placement.
The facility failed to implement proper infection control precautions for two residents. One resident, with severe cognitive impairment, did not have staff wearing gowns during high-contact care activities as required. Another resident, with a MRSA infection, was initially placed under incorrect precautions, and an LPN was observed handling a PICC line without PPE. These lapses highlight deficiencies in adhering to infection control protocols.
Failure to Implement Hot Liquid Safety Policy Results in Resident Burn
Penalty
Summary
A resident with a history of dementia, metabolic encephalopathy, diabetes mellitus type 2, and falls, who was on hospice care, sustained a second-degree burn after spilling hot coffee on himself. The facility failed to implement its hot liquid policy and did not accurately assess or provide adequate supervision for the resident, despite the resident's documented poor hand control and moderate to severe vision impairment. The resident's hot food/liquid assessment indicated high risk, but only a cup with a lid was recommended, and no other safety interventions were put in place. On the day of the incident, the Assistant Director of Nursing provided the resident with coffee, which was poured from a pot and prepared with cream and sweetener, then given to the resident with a lid. The staff member left to get coffee for another resident, during which time the resident spilled the coffee, resulting in burns to the inner thigh. Initial care involved applying a cold washcloth and later Silvadene cream, but there was no evidence of a wound assessment or additional treatment orders in the medical record. Subsequent documentation confirmed the presence of partial-thickness burns with blisters and open areas. Interviews and observations revealed that staff were not consistently aware of or following the facility's hot liquid temperature policy, with coffee temperatures exceeding the policy limit. Staff also lacked clarity on supervision requirements and the use of special equipment for high-risk residents. The Director of Nursing was unable to provide incident or accident reports for the burn and could not explain discrepancies in the resident's assessment documentation. Additionally, other residents had not been evaluated for hot liquid safety prior to being served, and staff were not consistently monitoring or documenting hot liquid temperatures as required.
Failure to Report Suspected Abuse and Neglect to Authorities
Penalty
Summary
The facility failed to report two separate incidents involving suspected abuse and neglect to the appropriate authorities as required by policy and regulation. In the first incident, a resident with severe mental impairment physically assaulted his roommate, who also had significant cognitive impairment, by hitting him with a water mug while the roommate was in bed. The assaulted resident sustained cuts, bruises, and a scratch, requiring evaluation and treatment at an emergency room. Although the incident was reported to the State Survey Agency, there was no notification to local law enforcement, contrary to facility policy and federal requirements. Documentation confirmed that the Nursing Home Administrator decided not to notify the police due to the mental condition of the residents, despite acknowledging that policy did not provide an exception for mental capacity. In the second incident, another resident, who was on hospice care and had dementia and metabolic encephalopathy, sustained a second-degree burn to his right thigh from a hot liquid spill. The injury was significant, with redness, blisters, and open areas measuring several centimeters. The Assistant Director of Nursing provided the resident with coffee, and shortly after, the resident was found with the spilled coffee and a burn on his thigh. The incident was not reported to the State Survey Agency, and there was no incident or accident report created at the time. The Director of Nursing, who started after the incident, was unaware of the event until later and confirmed that the injury was not reported as required. Both incidents demonstrate a failure to follow the facility's abuse and neglect reporting policy, which mandates immediate reporting of suspected abuse, neglect, or injuries of unknown source to the State Survey Agency and local law enforcement. Interviews with facility leadership confirmed awareness of the incidents and the lack of required reporting, with no justification found in policy for the omissions. The deficiencies were identified through record review and staff interviews, with documentation supporting the lack of timely and appropriate notification to authorities.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to initiate an investigation into an allegation of an injury of unknown origin for a resident who was admitted for a two-day respite stay under hospice care. The resident, who had Alzheimer's and Parkinson's, returned home with a swollen lip and bruising that were not present before the stay. The resident's durable power of attorney (DPOA) reported these injuries to the facility, and a hospice nurse assessed the injuries, noting bruising and swelling. Despite these reports, the facility did not initiate an investigation as required by their Abuse Prevention Program Policy. Interviews with facility staff revealed a lack of action in response to the reported injuries. The Medical Records Manager acknowledged receiving the complaint and forwarding it to the Administrator, who then delegated the follow-up to the Social Worker. However, no investigation was initiated by the Administrator or the Director of Nursing, as required by the facility's policy. The Director of Nursing did not interview staff or investigate the incident, despite being informed of the concerns. The facility's policy mandates immediate investigation of injuries of unknown origin, which was not adhered to in this case.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that call light systems were within reach for two residents, leading to a deficiency in accommodating the needs and preferences of each resident. Resident #142, an elderly female admitted for a hospice respite stay with a diagnosis of vascular dementia, was observed twice with the call light out of reach, tucked between the mattress and footboard. This resident was at high risk for falls, as indicated by a recent fall risk assessment, and had sustained an unwitnessed fall prior to the observations. The care plan for Resident #142 included interventions such as keeping the call light within reach and reminding the resident to use it for assistance, which were not adhered to. Similarly, Resident #30, an elderly female with dementia and recent fall-related injuries, was observed with the call light on the floor, out of reach. The care plan for this resident also specified that the call light should be within reach and that the resident should be encouraged to use it. Despite these care plan interventions, the facility did not have a specific policy in place regarding the placement of call lights, as confirmed by the administrator. This lack of adherence to care plans and absence of a specific policy contributed to the deficiency identified by the surveyors.
Failure to Implement Proper Infection Control Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) and Contact-Based Precautions for two residents, leading to deficiencies in infection control. For one resident, who had severe cognitive impairment and required assistance with all activities of daily living, the facility did not ensure that staff wore gowns during high-contact care activities as indicated by the signage on the resident's door. Despite the clear instructions, Certified Nurse Assistants (CNAs) were observed wearing only gloves during a transfer, contrary to the posted requirements. This oversight was due to a misunderstanding by the CNAs, who believed gowns were unnecessary for the resident's condition. Another resident, admitted with a MRSA infection in the right foot, was initially placed under Enhanced Barrier Precautions instead of the more stringent Contact Precautions required for their condition. An LPN was observed handling the resident's PICC line without donning any personal protective equipment, despite the presence of a sign indicating the need for EBP. The Infection Control Preventionist later acknowledged the error in precaution level, which was corrected after the initial observation. These lapses in following proper infection control protocols highlight the facility's failure to adhere to established guidelines for preventing the spread of infections.
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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 Gladwin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gladwin Pines Nursing And Rehabilitation Center | 2.2 mi | — | 16 | 0 |
| Medilodge Of Clare | 18.6 mi | — | 5 | 0 |
| The Villa At West Branch | 22.3 mi | — | 0 | 0 |
| North Woods Nursing Center | 22.7 mi | — | 0 | 0 |
| King Nursing & Rehabilitation Community | 23.8 mi | — | 0 | 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.