Gladwin Nursing and Rehabilitation Community

In the surveyor’s words

From the most serious findings on record at Gladwin Nursing and Rehabilitation Community, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 17, 2025

  This citation pertains to intake #MI00151153 Based on observations, interviews and record review, the facility a failed to implement their hot liquid policy, accurately assess and implement a safe hot liquid program for 1 Resident (R1) of four residents reviewed, resulting in a second-degree burn caused by a hot liquid. Findings included: A second-degree burn damages the full thickness of the skin causing redness, swelling, blisters and intense pain. Review of R1's face sheet, no date, revealed he was [AGE] years old, admitted on [DATE]. He was on hospice. He had diagnoses that included dementia, metabolic encephalopathy (brain disorder causing brain dysfunction), diabetes mellitus type 2, and falls. […]

• Actual harm, isolatedF689Oct 31, 2022

  This citation refers to MI00126719 Based on interview and record review, the facility failed to prevent a fall for 1 of 3 residents (R11), resulting in R11 sustaining a fracture from a fall. Findings include: A review of R11's undated Face Sheet revealed R11 was an [AGE] year-old resident admitted to the facility on [DATE]. In addition, R11's Face Sheet revealed multiple diagnoses that included dementia with behaviors, adult failure to thrive, left and right hip contractures, osteopenia (weak bones), and repeated falls. […]

• Actual harm, isolatedF684Aug 26, 2021

  Based on observation, interview and record review, the facility failed to provide care and services for 1 (Resident #20), resulting in an ineffective treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #20 admitted to the facility on [DATE] and has pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Brief Interview for Mental Status (BIMS) indicated she is cognitively intact. During an observation on 8/24/21 at 11:00 a.m., Resident #20 was in her room in her wheelchair and both eyes were slightly swollen, and the left eye was red and irritated in appearance. […]

• Actual harm, isolatedF710Aug 26, 2021

  Based on observation, interview and record review, the facility failed to notify the physician for 1 (Resident #20), resulting in an ineffective treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #20 admitted to the facility on [DATE] and has pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Brief Interview for Mental Status (BIMS) indicated she is cognitively intact. During an observation on 8/24/21 at 11:00 a.m., Resident #20 was in her room in her wheelchair and both eyes were slightly swollen, and the left eye was red and irritated in appearance. […]

• No harm, potential for more than minimal, widespreadF921Nov 15, 2022

  Based on observation, interview, and record review, the facility failed to maintain the potable water supply system, resulting in discolored water and potential for a contaminated water supply. These deficient practices affect all residents in the facility. Findings include: On 11/13/22 at 10:30 AM, the water coming out of the kitchen hand sink was observed to be discolored, appearing to be a grey/brown color. At this time, Dietary Cook U stated that the water isn't normally that color. On 11/13/22 at 11:05 AM, the water coming out of the bathroom sink of Room 29 and 31 was observed to be discolored. […]