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Complaint Investigation

Gladwin Pines Nursing And Rehabilitation Center

September 11, 2025 · Gladwin, MI · 449 Quarter Street
Citations 12
CMS Rating 1/5
Beds 84
Provider ID 235485
Healthcare Facility
Gladwin Pines Nursing And Rehabilitation Center
Gladwin, MI  ·  View full profile →
Inspection Summary

Gladwin Pines Nursing and Rehabilitation Center in Gladwin, MI — inspection on September 11, 2025.

Found 12 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0554
Resident Rights Deficiencies
Potential for More Than Minimal Harm

Federal health inspectors cited Gladwin Pines Nursing and Rehabilitation Center in Gladwin, MI for a deficiency under regulatory tag F-F0554 during a standard health inspection conducted on 2025-09-11.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Allow residents to self-administer drugs if determined clinically appropriate.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 12 deficiencies cited during this inspection of Gladwin Pines Nursing and Rehabilitation Center.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-06.

completed education on abuse reporting in October 2024.

During an interview on 09/11/2025 at 11:54 AM, R79's FRI investigation was reviewed with NHA. NHA confirmed that CNA B had not immediately reported the alleged neglect to the abuse coordinator per the facility policy and federal regulations and reported that there was no PNC (past noncompliance) completed regarding the deficient practice.

Review of the facility policy Abuse Prevention Overview last revised March 2019 revealed, .1.

Alleged incidents are reported immediately to the facility administrator and to the State Agency as required and outlined in the facility policy for reporting abuse.

Review of the facility policy Abuse/Suspected Abuse; Crime Investigation & Reporting last revised February 2023 revealed, .2.

Any person(s) witnessing or having knowledge of potential or actual abuse or crime must immediately report the incident to the Administrator and / or designee. In the case of a resident or family member, such a report can be made to the charge nurse or person assigned to receive complaints, who is responsible to follow through with reporting procedures. 3.

When allegations of resident (S483.5) mistreatment, abuse, crime, neglect, exploitation, misappropriation, or injuries of unknown source are reported, the administrator and designees will investigate the allegation with the assistance of appropriate personnel.

Facility ID:

Federal health inspectors cited Gladwin Pines Nursing and Rehabilitation Center in Gladwin, MI for a deficiency under regulatory tag F-F0658 during a standard health inspection conducted on 2025-09-11.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Ensure services provided by the nursing facility meet professional standards of quality.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 12 deficiencies cited during this inspection of Gladwin Pines Nursing and Rehabilitation Center.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-06.

Federal health inspectors cited Gladwin Pines Nursing and Rehabilitation Center in Gladwin, MI for a deficiency under regulatory tag F-F0677 during a standard health inspection conducted on 2025-09-11.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide care and assistance to perform activities of daily living for any resident who is unable.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 12 deficiencies cited during this inspection of Gladwin Pines Nursing and Rehabilitation Center.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-06.

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Federal health inspectors cited Gladwin Pines Nursing and Rehabilitation Center in Gladwin, MI for a deficiency under regulatory tag F-F0684 during a standard health inspection conducted on 2025-09-11.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Scope/Severity Level G: isolated, actual harm that is not immediate jeopardy.

Actual harm to residents was documented as a result of this deficiency.

This was one of 12 deficiencies cited during this inspection of Gladwin Pines Nursing and Rehabilitation Center.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-06.

Federal health inspectors cited Gladwin Pines Nursing and Rehabilitation Center in Gladwin, MI for a deficiency under regulatory tag F-F0686 during a standard health inspection conducted on 2025-09-11.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Scope/Severity Level G: isolated, actual harm that is not immediate jeopardy.

Actual harm to residents was documented as a result of this deficiency.

This was one of 12 deficiencies cited during this inspection of Gladwin Pines Nursing and Rehabilitation Center.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-06.

Federal health inspectors cited Gladwin Pines Nursing and Rehabilitation Center in Gladwin, MI for a deficiency under regulatory tag F-F0695 during a standard health inspection conducted on 2025-09-11.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide safe and appropriate respiratory care for a resident when needed.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 12 deficiencies cited during this inspection of Gladwin Pines Nursing and Rehabilitation Center.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-06.

Federal health inspectors cited Gladwin Pines Nursing and Rehabilitation Center in Gladwin, MI for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-09-11.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 12 deficiencies cited during this inspection of Gladwin Pines Nursing and Rehabilitation Center.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-06.

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Federal health inspectors cited Gladwin Pines Nursing and Rehabilitation Center in Gladwin, MI for a deficiency under regulatory tag F-F0849 during a standard health inspection conducted on 2025-09-11.

Category: Administration Deficiencies

The facility was found deficient in the following area: Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 12 deficiencies cited during this inspection of Gladwin Pines Nursing and Rehabilitation Center.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-06.

Federal health inspectors cited Gladwin Pines Nursing and Rehabilitation Center in Gladwin, MI for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-09-11.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Provide and implement an infection prevention and control program.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 12 deficiencies cited during this inspection of Gladwin Pines Nursing and Rehabilitation Center.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-06.

Federal health inspectors cited Gladwin Pines Nursing and Rehabilitation Center in Gladwin, MI for a deficiency under regulatory tag F-F0882 during a standard health inspection conducted on 2025-09-11.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 12 deficiencies cited during this inspection of Gladwin Pines Nursing and Rehabilitation Center.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-06.

Federal health inspectors cited Gladwin Pines Nursing and Rehabilitation Center in Gladwin, MI for a deficiency under regulatory tag F-F0921 during a standard health inspection conducted on 2025-09-11.

Category: Environmental Deficiencies

The facility was found deficient in the following area: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 12 deficiencies cited during this inspection of Gladwin Pines Nursing and Rehabilitation Center.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-06.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Gladwin, MI, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Gladwin Pines Nursing and Rehabilitation Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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