Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before 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 Pines Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment alleged that a night aide pushed her against the wall. The facility's investigation did not include interviews with all staff present during the shift when the incident was reported, including the night shift CNA and LPN, despite the resident's care plan requiring two-person assistance. This incomplete investigation did not meet regulatory expectations for thoroughness.
A resident with severe cognitive impairment alleged being pushed by a staff member, but the incident, related notifications, and the reason for a skin assessment were not documented in the medical record. Staff interviews confirmed that such documentation was required but missing, resulting in an incomplete and inaccurate record.
A resident with dementia and congestive heart failure was mistakenly given another resident's medications, including metoprolol and sotalol, leading to bradycardia and requiring hospital transfer. The error occurred when RN A prepared medications for two residents with the same first name and asked RN E to administer them, contrary to facility policy. The resident was monitored and evaluated at the emergency room following the incident.
The facility failed to document and address grievances for two residents. One resident, with a history of stroke and hypertension, reported unresolved issues with optometry care and other services, receiving no formal response despite discussions with staff. Another resident, with dementia and Parkinson's, had family complaints about inadequate care, which were not documented or addressed in writing by the facility. The DON and NHA acknowledged the lack of grievance documentation and response.
The facility failed to maintain accurate EHRs for two residents, leading to medication administration errors and incorrect legal documentation. A resident received the wrong medications despite orders to withhold them, and another resident's EHR inaccurately listed a family member as the DPOA after revocation. These discrepancies were not in line with the facility's documentation policy.
A LTC facility failed to implement its pressure injury management policy, leading to incomplete wound assessments and delayed healing for three residents. One resident's right heel wound worsened, resulting in hospital transfer for necrotizing fasciitis. Another resident's coccyx redness progressed to a Stage II open area without proper notification or treatment. A third resident's Stage II pressure injury lacked consistent treatment and care plan updates.
A facility failed to have policies and procedures for Medication Regimen Review (MRR) for a resident with multiple diagnoses. The pharmacist noted potential irregularities in the resident's medication regimen, but there was no written notice to the physician in the EMR. The Nursing Home Administrator acknowledged the absence of a written policy or procedures for MRR, leading to the deficiency.
The facility failed to implement an effective system for tracking staff illnesses, leading to inadequate documentation and surveillance of employee call-offs. The absence of an Infection Control Preventionist since mid-July contributed to this deficiency, as the process for handling call-offs was not properly managed. Numerous instances from February to June showed employees calling off sick without proper documentation or investigation, indicating a significant gap in infection control practices.
The facility failed to follow professional nursing standards for four residents. Two residents with heart failure were not weighed daily, and their providers were not notified of significant weight gains. A resident with hypertension did not receive prescribed clonidine despite qualifying blood pressure readings. Another resident with a PEG tube experienced inadequate site care, with dressings not changed as required, leading to soiled and painful conditions. These deficiencies highlight lapses in monitoring, communication, and adherence to medication administration policies.
The facility failed to secure medication carts and date opened insulin pens. Observations revealed unlocked and unattended medication carts in two halls, and undated insulin pens for two residents. An LPN confirmed the requirement for carts to be locked and insulin to be dated. The facility's policy mandates that medication storage areas be locked or attended.
A resident with dementia was found with bruising on her left ribcage, but the facility failed to promptly and thoroughly investigate the injury. The incident report was delayed, and the Director of Nursing and Nursing Home Administrator were not notified. The investigation lacked interviews with staff, residents, or visitors, and the injury was not reported to the State Agency, violating the facility's abuse prevention policy.
A resident with multiple health issues, including COPD and cachexia, lost their dentures at the facility, and the facility failed to promptly assist in replacing them. The resident's care plan did not document oral hygiene or denture care, and the Social Services Director was unaware of the missing dentures. Despite the facility's policy to replace lost dentures promptly, the dentures remained missing for 4-5 months.
A facility failed to implement an antibiotic stewardship program and accurately monitor an infection for a resident. The resident showed symptoms of a urinary tract infection, but no urine culture results were documented. Ciprofloxacin was prescribed without culture results, and McGeer Criteria documentation was missing. Staff interviews revealed that the urinalysis was incorrectly ordered, and further testing was not conducted. The facility's antimicrobial stewardship policy was not followed, and no audit was performed to evaluate the antibiotic order.
Failure to Conduct Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving a resident with severe cognitive impairment and multiple diagnoses, including late onset Alzheimer's Disease, anxiety, and generalized muscle weakness. The resident reported to the Social Services Director (SSD) that a night aide had pushed her against the wall, and this was also mentioned to an activity aide. The facility's 5-Day Investigation included interviews with the resident, the alleged perpetrator (CNA), a CNA hall partner from the earlier shift, and the activity aide. However, the investigation did not include interviews or written statements from key staff who were present during the shift when the alleged incident occurred, specifically the CNA hall partner from the night shift, the SSD who received the report, and the LPN assigned to the resident during the relevant hours. The Nursing Home Administrator (NHA) confirmed that she did not interview any staff members who worked from 10:00 PM to 6:00 AM, despite the alleged incident occurring during that time frame. Additionally, the resident's care plan indicated a two-person assist was required for incontinence care, but it was not determined if the night shift CNA assisted or witnessed the care provided. The facility's investigation and policy did not align with the State Operations Manual, which expects interviews with all relevant witnesses and staff present during the period of the alleged incident. This incomplete investigation led to the deficiency cited in the report.
Failure to Maintain Complete and Accurate Medical Record Following Resident Allegation
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident with late onset Alzheimer's Disease, anxiety, and generalized muscle weakness, who was severely cognitively impaired. The resident reported to the Social Services Director (SSD) that a night aide had pushed her against the wall, and this was noted during a psychosocial assessment. Although a 5-Day Investigation documented the incident, including notifications to the Nursing Home Administrator (NHA), Director of Nursing (DON), local authorities, health care provider, and the resident's guardian, there was no corresponding documentation in the resident's electronic medical record (EMR) or progress notes regarding the allegation, the notifications, or the reason for the skin assessment performed on the same day. Further review of the resident's progress notes and EMR revealed no mention of the reported incident, the notifications made, or the context for the follow-up interactions with the resident. Interviews with facility staff, including the SSD, RN, and NHA, confirmed that such incidents and notifications should have been documented in the resident's medical record. The lack of documentation regarding the incident, the notifications, and the rationale for assessments resulted in an incomplete and inaccurate medical record for the resident.
Medication Error Leads to Bradycardia and Hospital Transfer
Penalty
Summary
The facility failed to prevent significant medication errors for a resident, resulting in the resident becoming bradycardic and requiring hospital transfer. The resident, who had dementia and congestive heart failure, was mistakenly given another resident's medications, including metoprolol and sotalol, which can cause bradycardia. This error occurred on the morning of December 13, 2024, when RN A prepared medications for two residents with the same first name and asked RN E to administer them. RN E administered the medications prepared by RN A, leading to the resident receiving the wrong medications. The facility's policy states that only authorized personnel who prepare the medication may administer it, and medications supplied for one resident should not be administered to another. Interviews with RN A, RN E, and the Director of Nursing confirmed that the facility's policy was not followed, as RN E administered medications prepared by RN A. The resident's vital signs were monitored, and due to the low heart rate, the resident was evaluated at the emergency room for eight hours following the ingestion of the wrong medications.
Failure to Document and Address Resident Grievances
Penalty
Summary
The facility failed to document and address grievances according to its policy for two residents. Resident #102, who was admitted with diagnoses including cerebral infarction, weakness, and hypertension, reported ongoing issues with optometry care, mail receipt, voting privileges, and access to medical providers. Despite discussing these concerns with staff, including the Director of Nursing (DON), Resident #102 did not receive any written or formal response. The DON acknowledged that she did not assist Resident #102 in filling out a formal grievance, which should have included a written response. Similarly, Resident #103, who was admitted with dementia, Parkinson's disease, and a need for assistance with personal care, had ongoing complaints from a family member regarding inadequate care, such as being left wet and not being repositioned. The family member reported frequent conversations with staff, including the DON and Nursing Home Administrator (NHA), but did not receive any written response. The NHA admitted that the facility had not documented these grievances or provided a written response, acknowledging the need for improvement in grievance documentation and follow-up.
Inaccurate EHR Documentation for Two Residents
Penalty
Summary
The facility failed to maintain accurate Electronic Health Records (EHR) for two residents, leading to discrepancies in medication administration and legal documentation. Resident #101, who was admitted with dementia and congestive heart failure, received the wrong medications on the morning of December 13, 2024. Despite orders from the facility's medical doctor to withhold medications and monitor vital signs, the December 2024 Medication Administration Record (MAR) inaccurately documented that three medications were administered by Registered Nurse (RN) A. In a subsequent interview, RN A admitted to not administering the medications and expressed uncertainty about why the records were not updated to reflect this. For Resident #102, who was admitted with a history of cerebral infarction, weakness, and hypertension, the EHR inaccurately listed a family member as the Durable Power of Attorney (DPOA) despite the resident revoking this designation on October 22, 2024. The Social Services Director (SSD) confirmed the error and acknowledged the need to update the EHR to reflect the correct status of the family member as a responsible party rather than the DPOA. These inaccuracies in the EHR were not in accordance with the facility's policy on interdisciplinary documentation and admission assessments, which aims to ensure reliable and up-to-date resident information.
Inadequate Pressure Ulcer Management in LTC Facility
Penalty
Summary
The facility failed to implement its policy for pressure injury and wound management, resulting in incomplete wound assessments, delayed wound healing, and worsening of wounds for three residents. Resident #42, a female with diagnoses including dependence on a ventilator, heart failure, and pressure injuries, experienced a lack of comprehensive wound assessments and treatment changes despite the deterioration of her right heel wound. The wound assessments were not completed weekly, and the treatment order remained unchanged for four weeks, leading to the worsening of the wound and eventual transfer to the hospital for further evaluation due to necrotizing fasciitis. Resident #44, a female with dementia, had redness identified on her coccyx, which progressed to a Stage II open area. However, there was no documentation of notification to the responsible party or wound nurse, and no treatment was ordered or initiated at the time. The care plan was not updated, and the wound nurse was not informed, leading to a lack of appropriate intervention for the skin impairment. Resident #17, a female with a history of stroke, had a Stage II pressure injury on her left buttock, but there was no documentation of notification to the responsible party or wound nurse. The care plan was not updated, and the treatment was not consistently completed as per the treatment administration record. The facility's failure to conduct comprehensive wound assessments and update care plans contributed to the inadequate management of pressure injuries for these residents.
Lack of MRR Policies and Procedures
Penalty
Summary
The facility failed to develop and implement policies and procedures for Medication Regimen Review (MRR) for a resident, identified as R47, who was admitted with diagnoses including high blood pressure, thyroid disorder, anxiety, and depression. The pharmacist documented potential irregularities in the resident's medication regimen in March and April 2024, but there was no written notice to the physician about these irregularities in the Electronic Medical Record (EMR). During an interview, the Nursing Home Administrator (NHA) provided a memo from the pharmacist regarding the irregularities, but the section for the physician's response was left blank. The NHA admitted that the facility lacked a written policy or procedures for MRR, which contributed to the deficiency.
Inadequate Surveillance of Staff Illnesses
Penalty
Summary
The facility failed to implement an effective and current system of surveillance for staff illnesses, which is crucial for identifying possible communicable diseases and preventing outbreaks. The deficiency was highlighted during an interview with the Regional Nurse Consultant (RNC) and the Director of Nursing (DON), who reported the absence of an Infection Control Preventionist since mid-July. The infection control program was supposed to be a collaborative effort involving the RNC, DON, and the Regional Infection Control Preventionist (ICP), with the ICP responsible for tracking and surveillance of employee illnesses. However, the process for handling employee call-offs was inadequate, as the call-off slips were not properly documented or tracked, leading to a lack of real-time surveillance. The review of employee call-off logs from February to June revealed numerous instances where employees called off sick without adequate documentation of the type of illness, the unit they last worked on, or specific return-to-work dates. For example, in February, several CNAs called off sick without proper documentation, and there was no investigation into the cluster of illnesses. Similar issues were noted in March, May, and June, with multiple employees calling off sick without sufficient tracking or follow-up. The absence of detailed documentation and investigation into these illnesses indicates a significant gap in the facility's infection control practices. Additionally, the facility's policies on reportable health symptoms and infection prevention were not effectively implemented. The policy required employees to report specific symptoms to their supervisor, and the infection control practitioner was responsible for excluding or restricting employees from work based on these reports. However, the lack of surveillance and documentation suggests that these policies were not followed, leading to potential risks of undetected outbreaks. The facility's failure to maintain comprehensive records and conduct thorough investigations into employee illnesses highlights a critical deficiency in their infection prevention and control program.
Deficiencies in Nursing Practice and Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards of nursing practice in the treatment and medication administration for four residents. Resident #27, diagnosed with heart failure, was not weighed daily as ordered, and the provider was not notified of significant weight gain on specific dates. Similarly, Resident #56, also with heart failure, was not weighed daily, and the provider was not informed of a notable weight increase. These lapses in monitoring and communication could potentially impact the management of their heart conditions. Resident #32, who has hypertension, did not receive the prescribed medication, clonidine, on multiple occasions despite having blood pressure readings that met the criteria for administration. This inconsistency in medication administration could affect the resident's blood pressure management. The facility's policy on medication administration was not followed, as evidenced by the failure to administer clonidine as ordered and the lack of proper documentation. Resident #69, with a PEG tube for nutritional needs, experienced inadequate care of the tube site. The dressing was not changed as required, leading to soiled and painful conditions around the insertion site. The resident reported that the dressing was not changed for several days, and this was confirmed by a nurse practitioner's progress notes. The facility's failure to perform daily site care and document the treatment as completed contributed to the deficiency in care for this resident.
Medication Cart Security and Insulin Dating Deficiency
Penalty
Summary
The facility failed to secure medication carts and properly date opened insulin pens, leading to a deficiency. During an observation, the 500 hall medication cart was found unlocked and unattended by nursing staff. Additionally, opened insulin pens for a resident in bed 512-B, including Humalog Kwik pen, Basaglar pen, and Lantus solostar insulin pen, were found undated. An LPN confirmed that medication carts should be locked when not in use and insulin should be dated upon opening. In a separate observation, the 600 hall medication cart was also found unlocked and unattended. An opened Humalog Kwik pen for a resident in a specified room was undated. The facility's policy on medication storage, last reviewed in April 2021, requires that medication rooms, carts, and supplies be locked or attended by authorized personnel.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to thoroughly and promptly investigate an allegation of abuse for a resident, resulting in the potential for ongoing abuse during the investigation. The resident, a female with dementia, was found to have bruising on her left ribcage, which was tender to touch and measured 8cm x 1cm and 8cm x 5cm. The incident report was completed approximately 18 hours after the skin assessment identifying the injury, and there was no documentation that the Director of Nursing or Nursing Home Administrator were notified of the abnormal skin assessment/injury of unknown source. The investigation into the resident's injury was inadequate, as it did not include interviews or statements from facility staff, residents, or visitors. The Director of Nursing reported that the nursing staff on duty were interviewed to rule out a fall, but no other residents or visitors/family were interviewed to rule out physical abuse and/or neglect. The injury was not reported to the State Agency, and the investigation was concluded without a complete investigation into the injury. The facility's policy on abuse prevention and reporting was not followed, as the alleged incident was not reported immediately to the facility administrator and the State Agency. The policy requires a thorough investigation of all suspicions or allegations of abuse, including interviews with staff, residents, and visitors, and a review of the resident's medical record. The facility failed to take all necessary corrective actions depending on the results of the investigation, and the injury of unknown source was not reported to the State Agency as required.
Failure to Replace Lost Dentures
Penalty
Summary
The facility failed to promptly assist a resident in replacing lost dentures, which were lost at the facility. The resident, who was admitted with multiple diagnoses including COPD, acute respiratory failure, depression, anxiety, protein calorie malnutrition, and cachexia, was noted to have an upper denture upon admission. However, the resident's care plan, which was initiated shortly after admission, did not specifically document the provision of oral hygiene or denture care. During an observation, the resident was found without dentures, and the resident's Power of Attorney reported that the dentures had been lost at the facility some time ago, with no action taken to replace them. The Social Services Director was unaware of the missing dentures but mentioned having a set of unclaimed dentures in her office. The resident's Power of Attorney and daughter had reported the missing dentures to the facility staff months prior, but the dentures remained missing for 4-5 months. The facility's policy on Ancillary Services states that they will not charge residents for lost or damaged dentures when it is the facility's responsibility and that a prompt referral should be made within 3 business days for replacement. However, this policy was not followed in the case of the resident, leading to the deficiency.
Failure in Antibiotic Stewardship and Infection Monitoring
Penalty
Summary
The facility failed to implement and operationalize an antibiotic stewardship program and ensure accurate monitoring and documentation of an infection for a resident. The resident, an elderly female with a diagnosis of hypertension, was admitted to the facility and later showed symptoms suggestive of a urinary tract infection. A urinalysis was conducted, but no urine culture results were documented. Despite the absence of culture results, ciprofloxacin was prescribed and administered over three days. The facility's records did not include documentation of McGeer Criteria, which is a national standard for infection surveillance in long-term care facilities, to ensure the resident's urinary infection symptoms were appropriately tracked and treated. Interviews with facility staff revealed that the urinalysis was incorrectly ordered, which did not prompt the laboratory to conduct a culture and sensitivity test. The Infection Control Preventionist failed to review the urinalysis results and identify the need for further testing to ensure the appropriate antibiotic was prescribed. The facility's policy on antimicrobial stewardship, which requires obtaining appropriate cultures before administering antimicrobials and documenting indications for therapy, was not followed. Additionally, there was no prospective audit by the infection control practitioner, pharmacist, or licensed nurses to evaluate the appropriateness of the antibiotic order.
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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 Nursing And Rehabilitation Community | 2.2 mi | — | 13 | 0 |
| Medilodge Of Clare | 17.2 mi | — | 5 | 0 |
| North Woods Nursing Center | 21.8 mi | — | 0 | 0 |
| The Villa At West Branch | 24.1 mi | — | 0 | 0 |
| Medilodge Of Sterling | 24.7 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.