The nursing home failed to provide appropriate treatment and care according to residents' orders, preferences, and goals. Cited September 2025 — isolated incident, actual harm.
View the original federal record
F-Tag 684 — 42 CFR §483.25 — S/S: G
Nursing home report
Gladwin Pines Nursing and Rehabilitation Center
Gladwin, MI · Medicare-certified · 84 beds
Needs attention
For-profitChain member
1 of 5 overall
Gladwin Pines Nursing and Rehabilitation Center has a 1-star overall rating, with a 1-star health inspection rating, a recent federal penalty, and $144,208 in fines over the last 24 months. Staffing is rated 4 stars and reported nurse staffing is 4.33 hours per resident per day, above the federal benchmark of 4.1.
Facility ratings
Health inspections
Staffing
4.332 hrs/resident/day
Quality measures
Last inspection: September 11, 2025Penalties, last 24 months: $144,208recent federal penalty
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 4.332.
Staffing detail
- Registered nurses
- 0.92
- Licensed practical nurses
- 0.61
- Nurse aides
- 2.80
- Weekend nursing
- 4.06
Hours per resident per day.
Total staff turnover: 41%
Registered nurse turnover: 39%
Resident outcomes
How often residents experience these outcomes, with the direction over the past year.
Long-stay residents on antipsychotic medication
5%Improving
Residents with a fall causing major injury
4.1%Steady
Residents with pressure ulcers (bedsores)
6.2%Worsening
Residents with a urinary tract infection
2.9%Steady
Residents who lost too much weight
2.6%Steady
Residents who were physically restrained
0%Steady
Residents needing more help with daily activities
8.6%Worsening
Residents whose ability to walk got worse
24.4%Improving
Show all measures
Long-stay residents on antianxiety or sleep medication
33%Steady
Short-stay residents newly given an antipsychotic
0.4%Worsening
Residents with a long-term catheter
1.2%Worsening
Residents with new or worsening incontinence
26.5%Worsening
Residents with depressive symptoms
0%Steady
Long-stay residents given the seasonal flu vaccine
100%Steady
Long-stay residents given the pneumonia vaccine
100%Steady
Short-stay residents given the seasonal flu vaccine
95.2%Steady
Short-stay residents given the pneumonia vaccine
97.5%Worsening
What the inspectors found
The nursing home failed to provide proper pressure ulcer care and failed to prevent new pressure sores from developing. Cited September 2025 — isolated incident, actual harm.
View the original federal record
F-Tag 686 — 42 CFR §483.25(b) — S/S: G
The nursing home failed to ensure residents were free from significant medication errors. Cited January 2025 — isolated incident, actual harm.
View the original federal record
F-Tag 760 — 42 CFR §483.45(f)(2) — S/S: G
The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited June 2023 — isolated incident, actual harm.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: G
The home failed to make sure food was safely sourced, stored, prepared, and served according to professional standards. Cited September 2025 — widespread issue, potential for harm.
View the original federal record
F-Tag 812 — 42 CFR §483.60(i) — S/S: F
Recent history
- STAFFING
Reported nurse staffing met or exceeded the federal recommendation.
- PENALTY
A federal fine of $71,010 was recorded.
- INSPECTION
Health inspection found 12 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 2 health deficiencies.
See what inspectors found
- PENALTY
A federal payment denial was recorded.
- PENALTY
A federal fine of $17,345 was recorded.
- INSPECTION
Health inspection found 3 health deficiencies.
See what inspectors found
- PENALTY
A federal payment denial was recorded.
- PENALTY
A federal fine of $55,853 was recorded.
Penalties & enforcement
On record with Medicare: 3 fines · $144,208 in total fines · 3 payment denials.
- $71,010
Federal fine
Sep 11, 2025
- 12 days
Medicare/Medicaid payment denial
Jan 17, 2025
- $17,345
Federal fine
Jan 17, 2025
- 8 days
Medicare/Medicaid payment denial
Aug 7, 2024
- $55,853
Federal fine
Aug 7, 2024
- 33 days
Medicare/Medicaid payment denial
Jun 15, 2023
Operator & ownership
- Ownership
- For profit - Limited Liability company
- Chain
- Part of THE PEPLINSKI GROUP · 10 homes · 2.5 stars avg
- Occupancy
- 73.9 residents on an average day (88% of 84 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 37 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.