Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 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.
The facility failed to complete ordered monitoring and documentation for a resident with a stage 4 sacral wound, UTI, CHF, hypotension, and urinary retention, including delayed NPWT documentation, missing wound assessments, missed urine output entries, and Midodrine given without BP parameters. Multiple residents with CHF or heart failure also had missed daily or scheduled weights, with prior weights used in the TAR and no documentation explaining omissions or provider notification for significant weight gains.
A facility failed to carry out wound care and pressure injury prevention orders for multiple residents. One resident with a sacral ulcer had delayed and missed dressing changes, unimplemented off-loading and peri-wound orders, and ongoing stool contamination with worsening maceration. Another resident’s healed ischial wound was still documented as active, while ordered sacral soak and dressing changes were not entered. A third resident with dementia and paraplegia developed multiple worsening pressure injuries after an APM mattress was found in static mode, and the record also showed undocumented and overly frequent wound treatments.
A resident's personal food item was found in the Therapy Room refrigerator past the use-by date, and the CDM stated resident food items were not usually stored there. Surveyors also observed two wastewater drain lines from the ice machine and attached ice bin without air gaps, and the CDM was unaware the lines were not air gapped.
A resident with chronic respiratory failure, a trach, PEG tube, and nephrostomy catheter had repeated infections and multiple antibiotic courses for oral infections, pneumonia, bronchitis, sepsis, leukocytosis, and a UTI. The record showed only one root cause analysis, limited review of the infection pattern, and no documentation that EBP, PEG/nephrostomy care, or sterile trach care, suctioning, and oral care were verified. The IP reported no pattern was detected, and the DON said the resident’s infection history had not been reviewed in QAPI.
The facility failed to ensure a qualified IP was in place to manage and monitor the Infection Prevention and Control Program. Record review showed the IP became certified later, while the DON reported the prior IP had left and an interim corporate IP monitored the program from afar with an unclear schedule.
Medication administration errors were identified for three residents. One resident received Ultram 50 mg about 3 hours apart despite an order for q6h PRN, another resident’s eMAR showed more Ativan and Morphine doses administered than were signed out on the controlled drug record, and an RN was observed giving insulin from Novolog and Lantus pens without priming them first, contrary to manufacturer instructions and facility policy.
Unsafe and Unsanitary Environmental Conditions: Surveyors observed a call light cord wrapped around the handrail next to the toilet in a shower room, and the ESM stated it was not supposed to be wrapped there. Surveyors also observed the AVB on the sprayer line in the soiled linen room spilling water when the foot pedal was engaged, and the ESM was not aware it was not working correctly.
A resident with cerebral infarction and cognitive communication deficit was found to have eye drops in the room and was documented by nursing as independently self-administering Latanoprost, even though the admission self-administration assessment said the resident was not safe to self-administer meds. The resident could not identify prescribed meds or side effects, could not get meds from a locked drawer, and had not demonstrated the ability to request meds at appropriate times; an LPN and the DON were unsure why the medication was in the room or whether the resident had been evaluated as safe.
Failure to Immediately Report Alleged Neglect: A resident was found soaked in urine with a urine-soaked bed and heavily soaked clothing after staff and PT discovered the condition. The family member submitted a written allegation of neglect, but CNA B and an LPN did not immediately report the concern to the abuse coordinator, and the facility’s investigation later confirmed the allegation was not promptly reported.
Bathing Preferences Not Honored: A cognitively intact resident with polyneuropathy and need for assistance with personal care reported that showers were too painful and that he had received only bed baths for months, despite a care plan noting a preference for bed baths and an intervention to encourage whirlpool tub bathing. The resident said he had been offered a jacuzzi bath but staff told him they did not know how to use it, and CNAs confirmed they had never used the whirlpool tub.
Improper Sterile Technique During Tracheostomy Care: An RN provided trach care to a resident with Parkinson's Disease, Alzheimer's disease, and trach/vent dependence without using sterile gloves to replace the inner cannula and touched the outer cannula flange while placing the sterile cannula. The RT, DON, and Regional Clinical Support Nurse stated that inner cannula replacement during trach care was to be done using sterile technique.
A resident with dementia and complete paraplegia elected hospice, but the facility did not effectively coordinate care with hospice or maintain current hospice documentation. Hospice notes were missing from the EMR, the hospice binder contained an outdated coordinated plan of care, and staff did not document assessment or follow-up for new skin concerns and a new heel wound identified by hospice. The DON acknowledged communication with hospice needed to improve.
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.
Incomplete monitoring and documentation for wound care, urine output, medications, and CHF weights
Penalty
Summary
The facility failed to ensure timely and accurate assessment and monitoring for changes in condition for multiple residents with ordered weight monitoring, wound care, urine output tracking, and medication parameters. One resident admitted after a hospital stay for a UTI, stage 4 sacral pressure ulcer, CHF, diabetes, hypotension, and urinary retention had a wound vac delivered but not documented as received or located by staff, and the ordered NPWT was not documented as in place until several days later. Nursing documentation for the sacral wound was incomplete on multiple days, including missing wound condition details, drainage descriptions, odor, and confirmation that the dressing was sealed and functioning properly. The resident also had missed daily weights, missed urine output documentation on multiple shifts, and Midodrine was administered without the blood pressure parameters used by the hospital. In addition, a urine culture showing E. coli with an ESBL-producing profile was resulted, but the infection control preventionist did not notify the physician, and there was no documentation that any prescriber was informed before the resident’s death. Several residents with CHF or heart failure diagnoses did not receive ordered daily or scheduled weights, and the facility used prior weights in the treatment record when current weights were missing. One resident with CHF had multiple missed daily weights across July, August, and September, including periods where weights were not obtained for several consecutive days, and there was no documentation explaining the omissions. The record also showed weight gains of 5.6 lbs in one week and 4 lbs in one day, but there was no documentation that the provider was notified. Another resident with systolic and diastolic CHF had an order for weights Monday, Wednesday, and Friday, yet weights were missed on several dates, including a 6.2-lb gain over three days without documentation that the provider was notified. A third resident with chronic atrial fibrillation and CHF had multiple missed weights in July and August, with no rationale documented for the omissions. A fourth resident with heart failure also had missed weights on several ordered days, with no documentation explaining why the weights were not obtained. The regional nurse consultant confirmed that the residents had missing daily weights and that licensed nurses were using previous weights in the treatment administration record documentation. The facility did not have a CHF policy. The report also cited nursing textbook references stating that daily weights are an important indicator of fluid status and should be measured at the same time each day on the same scale.
Failure to Implement Wound Orders and Pressure Injury Prevention Measures
Penalty
Summary
The facility failed to implement pressure injury/wound management orders and failed to ensure ordered treatments and prevention interventions were carried out for three residents with pressure injuries. For one resident with a sacral pressure ulcer and osteomyelitis, wound clinic orders repeatedly changed over time, including Dakin’s solution cleansing, wet-to-dry dressings, peri-wound antifungal and skin protection treatments, frequent repositioning, and limiting time in a chair, but the facility did not timely transcribe or implement several of those orders. The care plan did not include the wound clinic’s off-loading and repositioning recommendations, and the record showed multiple missed or delayed treatments, as well as documentation that some ordered wound care continued to be charted as completed despite changes not being entered into the TAR. The same resident’s wound clinic notes documented ongoing stool contamination, maceration, rash, and worsening peri-wound skin, while the facility record showed that some wound clinic orders remained absent from the order summary for days to weeks. The record also showed that the resident’s wound was not reassessed for 10 days at one point, and that a Foley catheter was later discussed and ordered for moisture control before the wound clinic’s peri-wound treatments had been implemented. The facility acknowledged that wound clinic notes had been reviewed, but the treatment changes were still not reflected in the TAR at that time, and the care plan revisions did not include the wound clinic’s recommendations. For a second resident with a left ischial pressure ulcer, the wound clinic documented that the wound had healed, yet the facility continued to document the wound as healing and continued the treatment order instead of discontinuing it. The facility also did not transcribe wound clinic orders for acetic acid wound soak to the sacrum and Mepilex border dressing for the left ischium, and the care plan did not include the wound clinic’s off-loading, chair-time limitation, or bathing/hygiene instructions. For a third resident with dementia and complete paraplegia, the record showed a pressure injury developed after the alternating pressure air mattress was found in static mode, and the resident then developed multiple worsening wounds including a stage IV coccyx wound, stage II wounds, and suspected deep tissue injuries. The record also showed undocumented wound treatments and treatments documented more often than ordered.
Kitchen Food Storage and Ice Machine Drain Line Deficiencies
Penalty
Summary
The facility failed to maintain best practices in the kitchen when surveyors observed a resident's personal food item stored in the Therapy Room refrigerator with a use-by date of 9/1-9/4, and the Certified Dietary Manager stated that resident personal food items were not usually stored in that refrigerator and acknowledged it was past the use-by date on the sticker. Surveyors also observed two wastewater drain lines from the ice machine and attached ice bin that did not have air gaps, and the Certified Dietary Manager stated they were unaware the lines were not air gapped.
Failure to Implement Infection Prevention and Control Measures for a Resident With Recurrent Infections
Penalty
Summary
The facility failed to implement an effective Infection Prevention and Control Program for a physically compromised resident who had chronic respiratory failure with dependence on a ventilator, a tracheostomy, a gastrostomy tube, and a nephrostomy catheter. The resident’s record showed Enhanced Barrier Precautions were indicated, but there was no documentation that they were reviewed or verified as being implemented. There was also no documentation that proper care of the peg tube and nephrostomy catheter was verified, or that sterile technique was used with tracheotomy care, suctioning, and oral care. From April through September 2025, the resident experienced repeated infections and frequent antibiotic treatment, including treatment for oral infections, bronchitis, pneumonia, sepsis, leukocytosis with bilateral lung opacities, and a urinary tract infection. The record reflected a hospital admission for septic shock, multiple courses of antibiotics including amoxicillin, Rocephin, levofloxacin, ertapenem, cefepime, ceftriaxone, and Zithromax, and repeated episodes of respiratory decline with large amounts of yellow/green secretions, low oxygen saturation, increased work of breathing, and elevated white blood cell counts. One interdisciplinary note on the respiratory episode identified Loeb and McGeer criteria and stated the resident had a respiratory infection, with secretions and low oxygen levels listed as the root cause. The record reflected only one root cause analysis across this period, and that analysis was limited to the respiratory episode. The Infection Preventionist stated he had not detected any pattern of infections or antibiotic use and had not noted anything unusual about the resident’s care. The DON acknowledged multiple IPs held the role during the period and indicated the resident’s infection history had not yet been reviewed in Quality Assurance meetings. No additional information was provided by survey exit regarding the resident’s care or the implementation of the Infection Prevention and Control Plan.
Failure to Ensure a Qualified Infection Preventionist Was in Place
Penalty
Summary
The facility failed to ensure a qualified Infection Preventionist was in place to properly maintain, manage, and monitor the Infection Prevention and Control Program. Record review showed Infection Preventionist E was awarded IP certification on 7/2/2025. During an interview on 9/11/2025, the DON stated that the previous IP left the position on 4/26/2025 and that an interim IP at the corporate level was in place from 4/26/2025 until 7/2/2025. The DON reported the interim IP monitored the Infection Prevention and Control Program from afar and was in the building weekly or every couple of weeks, but she was not certain of the interim IP's schedule. No additional information was provided by the facility as of survey exit.
Medication Administration Errors and Documentation Mismatches
Penalty
Summary
The facility failed to follow standards of practice during medication administration for three residents. For one resident, the record showed an order for Ultram 50 mg every 6 hours as needed for pain, but two doses were dispensed and administered about 3 hours apart on the same day. A Regional Nurse Consultant confirmed the medication was given too soon and stated that a medication discrepancy was completed and education was being provided to the nurse. For another resident with respiratory failure requiring a tracheostomy and dependence on a ventilator, as well as muscular dystrophy, the electronic medication record showed three doses of Ativan 0.5 mg were administered on one day, while the controlled drug record showed only two doses signed out. The same resident’s record also showed two doses of Morphine 15 mg were administered that day, while the controlled drug record showed only one dose signed out. The DON stated that the eMAR and controlled drug records must match because that was the process used to reconcile controlled substances. For a third resident with diabetes mellitus, the nurse was observed preparing Novolog FlexPen and Lantus SoloStar insulin pens for administration without priming the pens first. The nurse stated there was no need to prepare the pens because they had the volume, and later stated she had reviewed the instructions and identified that the pens must be primed prior to use, adding, “I didn’t know.” The facility policy stated nurses must be familiar with the prescribed insulin device and always follow the manufacturer’s instructions.
Unsafe and Unsanitary Environmental Conditions
Penalty
Summary
The facility failed to provide a safe, functional, and sanitary environment when surveyors observed a call light cord wrapped around the handrail next to the toilet in the Hall 100 shower room, and the Environmental Services Manager stated the cord was not supposed to be wrapped around the handrail. Surveyors also observed in the Hall 300 soiled linen room that the atmospheric vacuum breaker on the sprayer line began spilling water when the foot pedal for the sprayer was engaged, and the Environmental Services Manager was not aware that the atmospheric vacuum breaker was not working correctly.
Failure to Determine Safe Self-Administration of Medication
Penalty
Summary
The facility failed to determine that one resident was safe to self-administer medication. The resident was admitted with diagnoses including cerebral infarction and cognitive communication deficit. On admission, the resident’s self-administration assessment indicated the resident was not safe to self-administer medication, with responses showing the resident was not able to identify prescribed medications and potential side effects, was not capable of getting medication out of a locked drawer, and had not demonstrated the ability to ask for medications at appropriate times for two days. Despite that assessment, the resident had an active physician order for Latanoprost eye drops, one drop in both eyes daily, and nursing medication administration notes documented that the resident independently administered the eye drops. During an observation and interview, the resident stated the eye drops were kept in a top drawer in the room, and two bottles of Latanoprost were observed in the drawer. An LPN stated she was not sure whether the resident had been evaluated as safe to self-administer medication, and the DON stated she was not sure why the eye drops were in the resident’s room and that the facility would re-assess the resident.
Failure to Immediately Report Alleged Neglect
Penalty
Summary
The facility failed to ensure staff immediately reported an allegation of neglect to the abuse coordinator for Resident #79. The resident was admitted to the facility and, according to the family member’s written statement, was found on 7/4/25 by PT and CNA B soaked head to toe in urine, with her bed soaked and her clothes heavily soaked and clinging to her body. The family member reported that the resident had been placed in bed fully clothed the prior afternoon and was later found in a urine-soaked bed, and the Resident Assistance Form documenting the concern was left under the administrator’s office door. The facility’s FRI investigation identified the allegation as neglect related to a lack of incontinence care from the night of 7/3/25, but the form was not identified until 7/7/25. CNA B stated he felt the situation was neglectful and reported his concerns to LPN D, but he did not immediately notify the abuse coordinator. LPN D also did not immediately notify the abuse coordinator after being informed of the allegation. The NHA confirmed that CNA B had not immediately reported the alleged neglect to the abuse coordinator and that no PNC was completed regarding the deficient practice.
Bathing Preferences Not Honored
Penalty
Summary
The facility failed to honor bathing preferences for a resident who was cognitively intact and required partial/moderate assistance with transfers and getting in and out of a tub or shower. The resident was admitted with diagnoses including infection and inflammatory reaction due to an internal right knee prosthesis, polyneuropathy, and need for assistance with personal care. During interview, the resident stated he did not take showers because the beating of the water from the shower was too painful, reported his last shower was about six months ago, and said he had only received bed baths since then. He also stated that bed baths were not the same. The resident’s care plan documented that he preferred bed baths only for comfort and also included an intervention to encourage whirlpool tub bathing. However, the resident reported he had been offered a jacuzzi bath but had not had one because no one knew how to use it. The DON stated the whirlpool tub was believed to be operational and said Peer Mentors were to be the trainers on its use. Two CNAs interviewed reported they had given showers to residents but had never used the whirlpool tub.
Improper Sterile Technique During Tracheostomy Care
Penalty
Summary
The facility failed to provide tracheostomy care using sterile technique for Resident #74, a female resident with Parkinson's Disease, Alzheimer's disease, and a tracheostomy with ventilator dependence. During observation, an RN provided trach care and replaced the inner cannula without donning sterile gloves, and while placing the sterile inner cannula, touched the flange of the outer cannula. Interviews with the RT, DON, and Regional Clinical Support Nurse confirmed that trach care was completed twice daily and that replacing the inner cannula during tracheostomy care was to be done using sterile technique.
Failure to Coordinate Hospice Care and Document Skin Assessments
Penalty
Summary
The facility failed to effectively communicate and coordinate hospice services for a resident admitted with dementia and complete paraplegia who had elected hospice care. The resident had active physician orders for hospice to evaluate and treat, and the care plan stated that hospice and the facility would coordinate care and services. However, the EMR had no hospice notes uploaded since the middle of August 2025, and the facility was unaware it had not received the last 30 days of hospice notes until the surveyor requested them. The hospice binder also contained an outdated coordinated plan of care dated February 2025, and the last hospice sign-in log entry was from 6/16/2025. Documentation showed that hospice identified new skin concerns and a new wound, but facility staff did not document assessment or follow-up in the EMR. A hospice RN noted redness to the back of the left knee and top of the right ankle and reported collaboration with a facility CCC, but there was no facility documentation that these areas were assessed or followed up. A hospice LPN identified a new right heel unstageable deep tissue injury and wrote a dressing order, yet the EMR did not show that the facility was aware of the wound or that the dressing was completed by facility staff. The DON acknowledged communication between the facility and hospice needed to improve, and the facility policy stated that hospice and the facility are responsible for their respective functions within the jointly developed plan of care.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 39 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 14 | 0 |
| Medilodge Of Clare | 17.2 mi | ★★★★★ | 5 | 0 |
| North Woods Nursing Center | 21.8 mi | ★★★★★ | 13 | 0 |
| The Villa At West Branch | 24.1 mi | ★★★★★ | 1 | 0 |
| Medilodge Of Sterling | 24.7 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 July 2026) and official state health department websites.