Gladwin Pines Nursing and Rehabilitation Center

In the surveyor’s words

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

• Actual harm, isolatedF684Sep 11, 2025

  Based on interview and record review, the facility failed to ensure residents received timely and accurate assessments and monitoring for changes in condition for five of eight residents (Resident #77, Resident #45, Resident #51, Resident #7, and Resident #46) reviewed for quality of care. Findings: Resident #77 (R77) Review of an admission Record revealed R77 was an [AGE] year-old-male, originally admitted to the facility on [DATE] following a 15-day hospital stay, with pertinent diagnoses of a urinary tract infection (UTI), a stage 4 pressure ulcer of the sacrum, congestive heart failure, diabetes mellitus, low blood pressure, and retention of urine. R77 was admitted to the facility as a full code and was able to answer questions. […]

• Actual harm, isolatedF686Sep 11, 2025

  Based on interview and record review, the facility failed to implement the facility policy for pressure injury/wound management and ensure treatments were ordered and completed, for 3 of 17 residents (Resident #15, #7, and #5), reviewed for the treatment and prevention of pressure injuries.Findings:Resident #15 (R15) Review of an admission Record revealed R15 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: pressure ulcer of the sacral region with osteomyelitis (infection in the bone.) Review of R15’s “Order Summary” dated 7/27/25 revealed an active order (as of 9/11/25) for “Dakins (full strength) External Solution 0.5 % (Sodium Hypochlorite) Apply to Coccyx Wound topically every shift for Wound cleansing.” Review of R15’s wound… […]

• Actual harm, isolatedF760Jan 17, 2025

  This citation pertains to intake #MI00149026. Based on interview and record review, the facility failed to prevent significant medication errors for 1 resident (Resident #101) of 4 residents reviewed for medication administration, resulting in Resident #101 (R101) becoming bradycardic (low heart rate) and requiring to be transferred to a local hospital for treatment. Findings include: Review of an Admission Record revealed Resident #101 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and congestive heart failure. Review of R101's Medication Discrepancy report, dated 12/13/2024 at 7:40 AM, revealed R101 received the wrong resident's medications the morning of 12/13/2024. […]

• Actual harm, isolatedF686Aug 7, 2024

  This citation pertains to intake # MI00141875 Based on interview and record review, the facility failed to 1.) implement the facility policy for pressure injury/wound management 2.) ensure pressure injury/wound assessments were comprehensive and accurate, and 3.) ensure treatments were ordered and completed, for 3 of 6 residents (Resident #42, #44, and #17) reviewed for alterations in skin integrity, resulting in incomplete wound assessments, a delay in wound healing, and the worsening of wounds. Findings: Resident #42 (R42) Review of an Admission Record revealed R42 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: dependence on ventilator, heart failure, and pressure injuries. […]

• Actual harm, isolatedF689Jun 15, 2023

  This citation pertains to intake # MI0013669. Based on observations, interviews, and record reviews, the facility failed to provide adequate supervision and assistance to prevent falls for 3 residents (R26, R40 and R122) of 4 Residents reviewed for falls resulting in, R40 sustaining multiple injuries including a fracture of spine and hip, and R26 and R122 having multiple falls with injuries that required emergency room treatment. Findings included: R40 Review of R40's face sheet, dated 6/14/23 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: left femur fracture (4/24/23), Alzheimer's Disease, muscle weakness, dysphagia (difficulty swallowing), unsteadiness on feet, and cognitive communication deficit. […]