Report
TheVardellReport
Gladwin Pines Nursing and Rehabilitation Center
Skilled nursing facility and nursing facility
449 Quarter Street
Gladwin, MI 48624
Report
← Gladwin Pines Nursing and Rehabilitation Center, free profile
Life by Vardell Presents
The Vardell Report.Gladwin Pines Nursing and Rehabilitation Center
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
- Provider Category
- Nursing home
- Location
- Gladwin, MI
- Record Period
- 2023–2025
- Source Documents
- 7
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Summary
Across 5 inspections from June 2023 to September 2025, state surveyors documented 30 findings at Gladwin Pines Nursing and Rehabilitation Center; 30 have a recorded correction; CMS lists 5 enforcement actions in the window.
- Inspections
- 5
- 2023–2025, standard and complaint
- Findings
- 30
- Deficiencies cited by state inspectors
- Corrected
- 30
- Of 30 findings, with a recorded correction date
- Penalties
- 5
- 3 fines; payment not published, 2 closed
Findings by Year
- Findings
- Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2023 | 1 | 5 | 1 |
| 2024 | 1 | 8 | 1 |
| 2025 | 3 | 17 | 3 |
| 2026 | 0 | 0 | 0 |
What the Record Shows
- 30 of 30 findings have a recorded correction date.
- CMS lists 5 enforcement actions in the window: 3 fines totaling $119,355, their payment not published; denial of payment imposed August 7, 2024, ended September 20, 2024; denial of payment imposed January 17, 2025, ended February 25, 2025.
- 4 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- The latest standard inspection, September 11, 2025, recorded 12 findings (most serious: Level G).
What to Ask About
- Investigating Alleged Violations, Cited in Two Inspections
- Professional Standards, Cited in Two Inspections
- Quality of Care, Cited in Two Inspections
- Pressure Injury Care, Cited in Two Inspections
- Medical Records, Cited in Two Inspections
- Infection Control, Cited in Two Inspections
- Citation F921, Cited in Two Inspections
Report at a Glance
- Facility
- Gladwin Pines Nursing and Rehabilitation Center
- Address
- 449 Quarter Street, Gladwin, MI 48624
- CMS Certification Number
- 235485
- Provider Type
- Skilled nursing facility and nursing facility
- Certified Beds
- 84
- Ownership
- For profit - Limited Liability company
- Record Window
- June 15, 2023 to October 1, 2026
Chronology
Inspection History
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- 2025
Standard health inspection
12 findings
The same visit included a complaint investigation.
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level GActual harmCorrected Oct 6, 2025
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Oct 6, 2025
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Oct 6, 2025
- F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Oct 6, 2025
- F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Level FNo actual harm, potential for moreCorrected Oct 6, 2025
- F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreCorrected Oct 6, 2025
- F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level ENo actual harm, potential for moreCorrected Oct 6, 2025
- F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Oct 6, 2025
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Oct 6, 2025
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Oct 6, 2025
- F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Oct 6, 2025
- F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.Level DNo actual harm, potential for moreCorrected Oct 6, 2025
Enforcement Action
Civil money penalty, $46,157 imposed September 11, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of September 11, 2025, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
2 findings
- F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Aug 11, 2025
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Aug 11, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
3 findings
- F760Ensure that residents are free from significant medication errors.Level GActual harmCorrected Feb 25, 2025
- F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Level DNo actual harm, potential for moreCorrected Feb 25, 2025
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Feb 25, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Standard health inspection
8 findings
The same visit included a complaint investigation.
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Sep 20, 2024
- F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level FNo actual harm, potential for moreCorrected Sep 20, 2024
- F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Sep 20, 2024
- F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreCorrected Sep 20, 2024
- F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level ENo actual harm, potential for moreCorrected Sep 20, 2024
- F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Sep 20, 2024
- F791Provide or obtain dental services for each resident.Level DNo actual harm, potential for moreCorrected Sep 20, 2024
- F881Implement a program that monitors antibiotic use.Level DNo actual harm, potential for moreCorrected Sep 20, 2024
Enforcement Action
Civil money penalty, $55,853 imposed August 7, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of August 7, 2024, the nearest before the penalty date.
Enforcement Action
Denial of payment imposed August 7, 2024. Status: Closed, September 20, 2024. CMS does not tie a penalty to a survey; listed with the standard health inspection of August 7, 2024, the nearest before the penalty date.
Enforcement Action
Civil money penalty, $17,345 imposed January 17, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of August 7, 2024, the nearest before the penalty date.
Enforcement Action
Denial of payment imposed January 17, 2025. Status: Closed, February 25, 2025. CMS does not tie a penalty to a survey; listed with the standard health inspection of August 7, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Standard health inspection
5 findings
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Aug 15, 2023
- F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level ENo actual harm, potential for moreCorrected Jul 12, 2023
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Jul 12, 2023
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Aug 15, 2023
- F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.Level DNo actual harm, potential for moreCorrected Jul 12, 2023
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
- 1
Investigating Alleged Violations, Cited in Two Inspections
Inspectors cited F610 in August 2024 and July 2025. This citation covers how the home responds to and investigates an allegation of abuse, neglect or mistreatment. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324252525F610 across all 5 inspections, oldest to newest - 2
Professional Standards, Cited in Two Inspections
Inspectors cited F658 in August 2024 and September 2025. This citation covers whether the home’s services meet professional standards of quality. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324252525F658 across all 5 inspections, oldest to newest - 3
Quality of Care, Cited in Two Inspections
Inspectors cited F684 in June 2023 and September 2025. This citation covers whether residents receive the treatment their orders, preferences and goals call for. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324252525F684 across all 5 inspections, oldest to newest - 4
Pressure Injury Care, Cited in Two Inspections
Inspectors cited F686 in August 2024 and September 2025. This citation covers how the home prevents and treats pressure injuries (bedsores). The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324252525F686 across all 5 inspections, oldest to newest - 5
Medical Records, Cited in Two Inspections
Inspectors cited F842 in January 2025 and July 2025. This citation covers whether resident records are complete, accurate and kept confidential. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324252525F842 across all 5 inspections, oldest to newest - 6
Infection Control, Cited in Two Inspections
Inspectors cited F880 in August 2024 and September 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324252525F880 across all 5 inspections, oldest to newest - 7
Citation F921, Cited in Two Inspections
Inspectors cited F921 in June 2023 and September 2025. The agency describes it this way: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324252525F921 across all 5 inspections, oldest to newest
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
- 01
When an allegation is made, who investigates it, and how are residents protected in the meantime?
Investigating Alleged Violations: cited in two inspections, most seriously at level D.
- 02
How do you check that nurses and aides follow professional standards, and what happens when they do not?
Professional Standards: cited in two inspections, most seriously at level E.
- 03
How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?
Quality of Care: cited in two inspections, most seriously at level G.
- 04
How often are residents checked for pressure injuries and repositioned, and who is responsible for it?
Pressure Injury Care: cited in two inspections, most seriously at level G.
- 05
How can a family request a resident’s records, and how are they kept accurate?
Medical Records: cited in two inspections, most seriously at level D.
- 06
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in two inspections, most seriously at level F.
- 07
What changed after F921 was cited, and how do you check it now?
Citation F921: cited in two inspections, most seriously at level E.
- 08
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
- 09
What led to the 2025 fine, and has it been paid?
A $46,157 civil money penalty was imposed September 11, 2025. CMS publishes the fine, not whether it has been paid. The record holds five enforcement actions in the window.
The Evidence
Sources and Coverage
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Michigan state survey agency.
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Michigan state survey agency
Inspection Jun 15, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Michigan state survey agency
Inspection Aug 7, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Michigan state survey agency
Inspection Jan 17, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Michigan state survey agency
Inspection Jul 9, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Michigan state survey agency
Inspection Sep 11, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Penalties, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Provider Information, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services · 235485
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Coverage
Record windowJune 15, 2023 – October 1, 2026
- CMS publishes about three inspection cycles; inspections before June 2023 are not in this release.
- CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
- Complaints not investigated onsite
- Allegations screened out by the state before an onsite visit are not published.
- Complaint allegations
- CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
- Facility-reported incidents
- Self-reported incidents appear only if they led to an inspection.
- Follow-up visits
- CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
- Fire safety inspections
- Published by CMS separately and not included in this record yet.
- Staffing levels and ownership history
- Published by CMS separately and not included in this record.
- Whether fines were paid
- CMS publishes the fines imposed, not whether or when they were paid.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.