Gladwin County

Gladwin Pines Nursing and Rehabilitation Center

Medicare rating
2 out of 5
5
findings of actual harm to a resident
17%
less nursing care than its residents are expected to need, against a research benchmark
$144,208
in federal fines recorded since 2024

Medicare’s overall rating for this home. The inspection part of it is graded on a curve against other Michigan homes, so a star here does not mean what it means in another state.

449 Quarter Street, Gladwin, MI 48624 · (989) 426-3430
84 beds · about 75 residents on a typical day · for-profit limited liability company

Staffing

All nursing staff, per resident, per day
4 hours 20 minutes

Residents here are expected to need about 5 hours 12 minutes, given how sick they are. This home reports 17% less. The average Michigan home reports 3 hours 59 minutes.

Registered nurses only
56 minutes

Registered nurses have the most training of the nursing staff on a shift. Residents here are expected to need about 1 hour 18 minutes of their time. This home reports 29% less.

Nursing staff who left in the past year
46%

About half of the nursing staff left within a year. High turnover means the people caring for your family member keep changing. The average Michigan home reports 44%.

Where the benchmark comes from

Staffing is the measure most closely linked to how residents do, and the one families almost never see. How much nursing care a resident needs depends on how sick they are, so we compare this home against the level its own residents are expected to need. The marker on the first two bars shows that level. It is a research benchmark, not a legal limit. The hours shown are the hours the home filed with Medicare, before any adjustment for how sick its residents are.

What inspectors found

Inspectors visit every nursing home and write up what they find. This home has 30 findings on record going back to 2023, 10 of them after someone filed a complaint. Of the 30, 25 are from the last three years.

The 5 serious findings here

Actual harm September 11, 2025

Quality of care

A resident did not get treatment and care that followed their orders, their own preferences and their goals.

The home fixed this on October 6, 2025.

Medicare’s wording

Federal tag F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Actual harm September 11, 2025

Bedsores

The home did not prevent or properly treat pressure sores.

The home fixed this on October 6, 2025.

Medicare’s wording

Federal tag F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Actual harm January 17, 2025 From a complaint

Medication errors

The home did not keep a resident free of a significant medication error.

The home fixed this on February 25, 2025.

Medicare’s wording

Federal tag F760Ensure that residents are free from significant medication errors.

Actual harm August 7, 2024 From a complaint

Bedsores

The home did not prevent or properly treat pressure sores.

The home fixed this on September 20, 2024.

Medicare’s wording

Federal tag F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Actual harm June 15, 2023

Accidents and supervision

The home did not keep the building free of hazards, or did not supervise a resident closely enough to prevent an accident.

The home fixed this on August 15, 2023.

Medicare’s wording

Federal tag F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Everything on record

Immediate jeopardy 0 Has caused, or was likely to cause, serious injury, harm, impairment or death
Actual harm 5 A resident was hurt
Potential for harm 25 Could have caused harm. No one was hurt. The most common kind.

365 of the 422 nursing homes in Michigan have fewer findings of harm or immediate jeopardy on record than this one.

Medicare has blocked payment for new admissions at this home 2 times, for 20 days in total. The most recent block lasted 12 days and started February 13, 2025.

What these levels mean

Immediate jeopardy The most serious finding there is. Medicare’s words: noncompliance that has caused, or is likely to cause, serious injury, harm, impairment, or death. About 2 in every 100 findings nationally.

Actual harm A resident was really hurt, not just put at risk. About 3 in every 100 findings.

The letter is Medicare’s own code for how many residents were involved. Immediate jeopardy covers J, K and L. Actual harm covers G, H and I. The later the letter, the more residents were affected.

The plain-English line under each finding describes the rule the inspector cited. It is not an account of what happened. Medicare’s own wording of the rule is printed with it, and the full inspection report is the record of the incident.

What you can do

Numbers only go so far. These are two things most families do not know they can do.

Ask for today’s staffing sheet

Every nursing home must post how many nurses are working each shift, keep 18 months of it, and show it to you on request. Ask for today’s, then last Saturday’s. Weekends are when staffing thins out.

Call the ombudsman before you decide

Every state has a free, confidential long-term care ombudsman. You can ask how many complaints a specific home has had and what they were about. You can find your state’s office through its department of aging.

Where this comes from

Inspection findings, staffing hours, fines and star ratings on this page are published by the Centers for Medicare & Medicaid Services, a federal agency, and are current as of August 1, 2026. We reload after each monthly release, and the footer of every page shows both the release date and the date we loaded it. The federal ID for this home is 235485.

What these numbers do not say

Fines can be appealed and reduced. The amount shown is what CMS had recorded as of this release. Medicare’s penalties file covers a rolling window of the last few years rather than a home’s whole history, so this is what Medicare publishes today and not everything this home has ever been fined. The year beside the figure above is the earliest fine Medicare still lists for it.

The level of care residents here are expected to need, and the gap, are not Medicare figures. We work them out from this home’s own Medicare case-mix score using the published CASE formula (Harrington and others, Journal of the American Geriatrics Society, 2025). It is a research benchmark, not a legal limit.

Inspection findings are recorded by state inspectors on behalf of Medicare. Staffing hours come from payroll records the home files with Medicare, and Medicare audits a sample of them. Star ratings partly reflect quality measures the home reports about itself, which is why we show inspections and staffing separately rather than only the star.