Gladwin Pines Nursing and Rehabilitation Center

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

53.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 75 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 43.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 48 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.23 therapist hours per resident per day in 2026Q1 — more than 29% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 84 beds and averages 75.0 residents a day — about 89% occupied, or roughly 9 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.33 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.93 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.88 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.05 hrs/resident/day on weekends vs 4.44 on weekdays — 9% thinner on weekends. RN hours go from 1.05 to 0.64 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

30 citations, most serious first. The 15 most serious are shown; the remaining 15 are one tap away and print in full.

• Actual harm · Gcited before2025-09-11 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: Resident #77 (R77) Review of an admission Record revealed R77 was an [AGE] year-old-male, originally admitted to the facility on [DATE] following a 15-day hospital stay, with pertinent diagnoses of a urinary tract infection (UTI), a stage 4 pressure ulcer of the sacrum, congestive heart failure, diabetes mellitus, low blood pressure, and retention of urine. R77 was admitted to the facility as a full code and was able to answer questions. Review of an Inpatient Discharge Summary for R77 dated 07-24-25 at 10:58 AM reflected the following information regarding R77's hospital stay and discharge orders: (a) on 07-14-25, R77 had a surgical excision and debridement of a stage 4 sacral wound, and a wound vacuum (negative…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-09-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings:Resident #15 (R15) Review of an admission Record revealed R15 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: pressure ulcer of the sacral region with osteomyelitis (infection in the bone.) Review of R15’s “Order Summary” dated 7/27/25 revealed an active order (as of 9/11/25) for “Dakins (full strength) External Solution 0.5 % (Sodium Hypochlorite) Apply to Coccyx Wound topically every shift for Wound cleansing.” Review of R15’s wound clinic “Physician Orders Details” dated 8/1/25 revealed, “…The periwound skin appearance exhibited: Maceration, Rubor…Wound Treatment-Wound #2 Coccyx Cleanser: Dakins Solution 0.5 % 3 X Per Day…Use FULL STRENGTH DAKIN’S SOLUTION…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-01-17 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This 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. Findings include: Review of an admission Record revealed Resident #101 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and congestive heart failure. Review of R101's Medication Discrepancy report, dated 12/13/2024 at 7:40 AM, revealed R101 received the wrong resident's medications the morning of 12/13/2024. Further review revealed the facility Medical Doctor (MD) K was contacted by Registered Nurse (RN) A. Facility MD K gave orders for nursing staff to monitor R101's vital signs and hold his morning medications. Review of R101's Provider Progress Notes, dated 12/13/2024 at 11:07 AM, revealed MD K documented R101…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-08-07 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This 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. Findings: Resident #42 (R42) Review of an admission Record revealed R42 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: dependence on ventilator, heart failure, and pressure injuries. Review of R42's Wound Measurement dated 5/1/24 revealed, .right heel 3.2 x 3.4 unstageable . Heel has large eschar cap . Consider wound care clinic referral . No additional wound description reflected in the wound assessment. Comprehensive wound assessments are to include location,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-06-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This 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. Findings included: R40 Review of R40's face sheet, dated 6/14/23 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: left femur fracture (4/24/23), Alzheimer's Disease, muscle weakness, dysphagia (difficulty swallowing), unsteadiness on feet, and cognitive communication deficit. R40 was not her own responsible party. Review of R40's incident and accident report dated 2/11/2023 at 6:43 PM revealed she had an unwitnessed fall and staff were notified of the fall by another resident. There was no indication if the resident's care plan…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-09-11 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A)…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-09-11 · tag F0880 — failed to prevent and control infections — widespread
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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. Findings include:Review of the admission Record reflected R74 originally admitted to the facility 4/12/21 with current diagnoses that included: Chronic Respiratory Failure with Dependence on a Ventilator, Tracheostomy, and Gastrostomy (feeding or peg tube). The medical record reflected R74 also had a nephrostomy catheter. The medical record reflected Enhanced Barrier Precautions (EBP. An elevated level in the use of personal protective equipment) during high contact resident care.Review of the Electronic Medical Record (EMR) revealed a history of frequent infections with antibiotic therapy and included:April 2025The EMR reflected in April R74 had received Amoxicillin (an antibiotic) via peg tube for…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-09-11 · tag F0882 — widespread
  Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
  What the surveyor found here — the official record, unedited, may be distressing

  Based 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. Findings include: Review of the document provided by the facility reflected Infection Preventionist (IP) E was awarded an IP certification on 7/2/2025.On 9/11/2025 at 11:14 AM an interview was conducted with the Director of Nursing (DON) in her office. The DON reported, due to a staff vacancy, prior to 7/2/2025 an interim IP was in place. The DON later reported the previous IP left the position on 4/26/2025. The DON indicated an interim IP at the corporate level was in place from 4/26/2025 until 7/2/2025. The DON reported the interim IP monitored the Infection Prevention and Control Program from afar. The DON reported the Interim IP was in weekly or every couple of weeks. The DON reported she was not certain of the interim IP's schedule. As of survey exit no additional information was provided by the facility.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-09-11 · tag F0658 — failed to meet professional standards of care — pattern
  Ensure services provided by the nursing facility meet professional standards of quality.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: Resident #67 (R67) Review of an admission Record revealed R67 was a [AGE] year-old female, admitted to the facility on [DATE]. Review of R67’s “Order Summary” dated 2/2/22 revealed, “Ultram Tablet 50 MG (traMADol HCl) .Give 1 tablet by mouth every 6 hours as needed for pain.” Review of R67’s “Controlled Drug Receipt/Record/Disposition Form” revealed that on 8/4/25 a dose of Ultram was dispensed at 5:08 AM and again at 8:04 AM. (Approximately 3 hours apart). Review of R67’s August “Medication Administration Record” confirmed that the doses of Ultram were administered at 5:08 AM and 8:04 AM. During an interview via email on 09/11/2025 at 4:23 PM, Regional Nurse Consultant (RNC) “A” confirmed R67’s Ultram was administered 3 hours apart which did not follow the providers…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-09-11 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
  Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
  What the surveyor found here — the official record, unedited, may be distressing

  Based 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: Findings include: On 9/9/2025 at 2:50PM, observed, in Hall 100 shower room, there was a call light cord wrapped around the handrail next to the toilet. Environmental Services Manager (ESM) M indicated the cord was not supposed to be wrapped around the handrail. On 9/9/2025 at 3:08PM, observed, in Hall 300 soiled linen room, the atmospheric vacuum breaker (AVB) on the sprayer line began spilling water when the foot pedal for the sprayer was engaged. ESM M was not aware the AVB was not working correctly.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-09-11 · tag F0554 — isolated
  Allow residents to self-administer drugs if determined clinically appropriate.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include:Review of an admission Record revealed R73 admitted to the facility on [DATE] with pertinent diagnoses which included cerebral infarction and cognitive communication deficit (difficulty with effective verbal and nonverbal communication, stemming from impairments in cognitive functions like attention, memory, reasoning, and problem-solving). Review of R73's Self-Administration of Medication assessment, completed upon admission on [DATE], revealed R73 was deemed unsafe to self-administer medication. Further review revealed .The resident is able to identify the medications prescribed & verbalize knowledge of potential side effects.No.The resident is capable of getting medication out of the locked drawer.No.The resident has demonstrated the capability of asking for his/her medications…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-09-11 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This 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.Findings:Resident #79 (R79)Review of an admission Record revealed R79 was an [AGE] year-old female, admitted to the facility on from 6/24/25 to 7/17/25.Review of R79's Resident Assistance Form completed by R79's Family Member (FM) C revealed, It was reported to me when I arrived (07/04 ~9:45-10 AM) by (Certified Nursing Assistant [CNA] B) that PT (physical therapy) found mom soaked head to toe (and bed soaked) with urine and that the stench from her room was overwhelming. Her room still smelled when I arrived. PT almost had to cut of mom's clothes to remove them because they were so heavily soaked and clinging to her body.(CNA B) stated that he was told mom's assistant claimed mom refused care. For mom, this cannot be true! Mom is extra conscientious about her toileting…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-09-11 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to honor bathing preferences for one resident (R39). Findings include:Review of the admission Record reflected R39 originally admitted to the facility 7/1/2022 with current pertinent diagnoses that included infection and inflammatory reaction due to internal right knee prothesis, polyneuropathy (a disease affecting peripheral nerves and features weakness and burning pain), and need for assistance with personal care. Review of the Minimum Data Set (MDS) dated [DATE] reflected R39 was cognitively intact and required partial/moderate assistance with transfers from bed to chair and to get in and out of a tub or shower.During an interview conducted on 9/9/2025 at approximately 10:45 AM, R39 reported he did not take showers because the beating of the water from the shower was too painful. R39 reported his last shower was about six months ago and has had only bed baths since then. R39 reported bed baths are not the same. R39 reported he had been offered a jacuzzi…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-09-11 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings:Resident #74 (R74) Review of an admission Record revealed R74 was an [AGE] year-old female, last admitted to the facility on [DATE], with pertinent diagnoses of Parkinson's Disease, Alzheimer's, and a tracheostomy and ventilator dependent. During an observation on 09-09-25 at 11:45 AM, Registered Nurse (RN) P provided trach care to R74 which included replacing the inner cannula. RN P did not don sterile gloves to handle and place the inner cannula into the tracheostomy and while placing the sterile inner cannula, touched the flange of the outer cannula. During an interview on 09-09-25 at 1:46 PM, Respiratory Therapist (RT) O stated that trach care was completed twice daily and replacing the inner cannula was done utilizing sterile technique. During an interview on 09-10-25 at 8:45 AM, the Director of Nursing and the Regional…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-09-11 · tag F0849 — isolated
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Review of an admission Record revealed R5 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and complete paraplegia (loss of motor and sensory function). Review of R5's active Physician's Orders, revised 2/17/2025, revealed .Hospice to Eval and treat. Review of a current end of life Care Plan intervention for R5, revised 2/24/2025, revealed .Hospice has been elected and the facility & hospice will coordinate care & services. Review of R5's Electronic Medical Record (EMR) on 9/10/2025 at 1:58 PM revealed no hospice notes uploaded since the middle of August 2025. In an interview on 9/11/2025 at 9:39 AM, undocumented treatments of dressing changes on the Treatment Administration Record (TAR) were discussed with the Director of Nursing (DON) and Regional Nurse A. The DON reported…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$144,208 in federal fines across 3 penalties. 2 Medicare payment denials on record.

• $71,010 — penalty dated 2025-09-11
• $17,345 — penalty dated 2025-01-17
• $55,853 — penalty dated 2024-08-07
• Medicare payment denial — starting 2025-02-13 for 12 days
• Medicare payment denial — starting 2024-09-12 for 8 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to THE PEPLINSKI GROUP — 10 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 23 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

About 77% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in MI