Gladwin Pines Nursing and Rehabilitation Center

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the kitchen resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 9/09/2025 at 11:00AM, during the initial walkthrough, it was observed that there was a resident's personal food item in the Therapy Room refrigerator dated 9/1-9/4. Certified Dietary Manager (CDM) L said that resident's personal food items were not usually stored in the Therapy Room refrigerator, and she noted it was past the use-by date on the sticker. According to the 2022 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: [...]

Inspectors wroteBased on interview and record review the facility failed to implement an effective Infection Prevention and Control Program for a physically compromised Resident (R74) resulting in frequent infections and frequent and aggressive antibiotic therapy without analysis of recurrence, efforts to determine root cause, or actions to ensure proper implementation of infection prevention measures.

Inspectors wroteBased on interview and record review, the facility failed to ensure a qualified Infection Preventionist was in place to properly maintain, manage, and monitor the Infection Prevention and Control Program.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standards of practice during medication administration for three residents' (Resident #29, Resident #67, and Resident #58) out of 17 residents reviewed.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, functional and sanitary environment resulting in an increased potential for contamination of the water supply and a possible decrease in safety for all residents:

Inspectors wroteBased on observation, interview, and record review the facility failed to determine a resident as safe to self-administer medication for 1 resident (R73) of 2 residents reviewed for self-administration of medication.

Inspectors wroteThis citation pertains to intake # 2569423Based on interview and record review, the facility failed to ensure facility staff immediately reported an allegation of neglect to the abuse coordinator for 1 resident (Resident #79) reviewed for neglect.

Inspectors wroteBased on interview and record review the facility failed to honor bathing preferences for one resident (R39).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide tracheostomy care using sterile technique for one of three resident's (Resident #74) reviewed.

Inspectors wroteBased on interview and record review, the facility failed to effectively communicate and coordinate resident care with hospice for one resident (R5) of 1 resident reviewed for hospice.

Inspectors wroteThis citation refers to MI00152903. Based on interview and record review, the facility failed to conduct a thorough investigation for 1 of 3 residents (R2) reviewed for abuse/neglect.

Inspectors wroteThis citation refers to MI00152903. Based on interview and record review, the facility failed to maintain a complete and accurate medical record for 1 of 3 residents (R2) reviewed.

Inspectors wroteThis 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.

Inspectors wroteThis citation pertains to intake #MI00147001. Based on interview and record review, the facility failed to document resident concerns according to facility policy for 2 residents (Resident #102 and #103), of 4 residents reviewed for grievance resolution.

Inspectors wroteBased on interview and record review, the facility failed to maintain an accurate Electronic Health Record (EHR) for two residents (Resident #101 and #102), of 5 residents reviewed for accuracy of medical records.

Inspectors wroteThis 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.

Inspectors wroteBased on interview and record review, the facility failed to ensure that policies and procedures were developed and implemented for one resident (R47) of five reviewed for Medication Regimen Review (MRR) that address time frames for steps in the MRR process and steps the pharmacist must take when an irregularity requires urgent action.

Inspectors wroteBased on interview and record review, the facility failed to implement an effective and current system of surveillance for staff illnesses to identify possible communicable diseases and infections to prevent the spread of an illness/outbreak, resulting in the potential for an outbreak to go undetected.

Inspectors wroteThis citation pertains to intake # MI00141875 Based on interview and record review, the facility failed to follow professional standards of nursing practice for treatment and medication administration for 4 residents (Resident #27, #32, #56, and #69), out of 10 residents reviewed for the provision of nursing services.

Inspectors wroteThis citation pertains to intake # MI00141875 Based on observation, interview, and record review, the facility failed to secure 2 of 5 medication carts and date opened insulin pens.

Inspectors wroteThis citation pertains to intake # MI00141875 Based on interview and record review, the facility failed to thoroughly and promptly investigate an allegation of abuse for 1 resident (Resident #44) out of 3 residents reviewed for abuse, resulting in the potential for ongoing abuse during the investigation

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #11) out of 18 residents reviewed for dental services, was promptly assisted in replacing dentures lost at the facility.

Inspectors wroteBased on interview and record review, the facility failed to 1.) implement, and operationalize an antibiotic stewardship program and 2.) ensure accurate monitoring and documentation of an infection for 1 resident (Resident #32) out of 3 residents reviewed for antibiotic use and treatment.

Inspectors wroteThis 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.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 73 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased air quality.

Inspectors wroteBased on interview, observation, and record review, the facility failed to protect the dignity and respect of two residents, (Resident #221 and Resident #171) reviewed for dignity and respect. The deficient practice resulted in Resident #221 (R221) and Resident #171 (R171) with feelings of frustration and disrespect when their care was not provided timely and in a dignified manner.

Inspectors wroteBased on interview and record review, the facility failed to assess and monitor blood sugars for one resident, Resident #43 (R43) reviewed for diabetes management. This deficient practice had the potential for R43's symptoms of hypoglycemia and/or hyperglycemia to go untreated causing an avoidable complication and decline in health status.

Inspectors wroteBased on interview, observation, and record review, the facility failed to assess and monitor a peripherally inserted central catheter (PICC) for one resident, Resident #43 (R43) reviewed for PICC management. The deficient practice placed R43 at risk for the PICC line to migrate and sustain a subsequent infection or the catheter to dislodge.