Gladwin Pines Nursing and Rehabilitation Center
449 Quarter Street · Gladwin, MI · 48624 · 9894263430
84 certified beds For profit - Limited Liability company Chain: The Peplinski Group
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $144,208 in fines in the last 24 months.
- 5 citations involved actual harm to residents.
- Staffing hours comfortably above national benchmarks.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
2 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
$144,208 in federal fines in the last 24 months
3 fines — CMS fines are reserved for verified, serious non-compliance.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 4 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 4.33 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.92 | 0.55–0.75 |
| Weekend hours / resident-day | 4.06 | ≈ weekday level |
| Nursing turnover / year | 41% | median 45% |
| Fines (3-yr window) | 3 · $144,208 |
Inspection citations (30 in the current record)
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Actual harm · G September 11, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected October 6, 2025 · Quality of Life and Care
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Actual harm · G September 11, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected October 6, 2025 · Quality of Life and Care
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Potential for harm · D September 11, 2025
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected October 6, 2025 · Resident Rights
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Potential for harm · E September 11, 2025
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected October 6, 2025 · Resident Assessment and Care Planning
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Potential for harm · D September 11, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected October 6, 2025 · Quality of Life and Care
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Potential for harm · D September 11, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Corrected October 6, 2025 · Quality of Life and Care
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Potential for harm · F September 11, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected October 6, 2025 · Nutrition and Dietary
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Potential for harm · D September 11, 2025
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.
Corrected October 6, 2025 · Administration
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Potential for harm · F September 11, 2025
Provide and implement an infection prevention and control program.
Corrected October 6, 2025 · Infection Control
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Potential for harm · F September 11, 2025
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected October 6, 2025 · Infection Control
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Potential for harm · E September 11, 2025
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected October 6, 2025 · Environmental
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Potential for harm · D September 11, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected October 6, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D July 9, 2025 · found via complaint
Respond appropriately to all alleged violations.
Corrected August 11, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D July 9, 2025 · found via complaint
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected August 11, 2025 · Resident Assessment and Care Planning
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Actual harm · G January 17, 2025 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected February 25, 2025 · Pharmacy Service
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Potential for harm · D January 17, 2025 · found via complaint
Honor 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.
Corrected February 25, 2025 · Resident Rights
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Potential for harm · D January 17, 2025 · found via complaint
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected February 25, 2025 · Resident Assessment and Care Planning
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Actual harm · G August 7, 2024 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected September 20, 2024 · Quality of Life and Care
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Potential for harm · F August 7, 2024
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected September 20, 2024 · Pharmacy Service
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Potential for harm · D August 7, 2024
Provide or obtain dental services for each resident.
Corrected September 20, 2024 · Quality of Life and Care
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Potential for harm · F August 7, 2024
Provide and implement an infection prevention and control program.
Corrected September 20, 2024 · Infection Control
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Potential for harm · D August 7, 2024
Implement a program that monitors antibiotic use.
Corrected September 20, 2024 · Infection Control
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Potential for harm · D August 7, 2024 · found via complaint
Respond appropriately to all alleged violations.
Corrected September 20, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E August 7, 2024 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected September 20, 2024 · Resident Assessment and Care Planning
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Potential for harm · E August 7, 2024 · found via complaint
Ensure 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.
Corrected September 20, 2024 · Pharmacy Service
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| September 11, 2025 | Fine | $71,010 |
| January 17, 2025 | Fine | $17,345 |
| January 17, 2025 | Payment Denial | 12 days |
| August 7, 2024 | Fine | $55,853 |
| August 7, 2024 | Payment Denial | 8 days |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 235485 · certified since April 14, 1989. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.