Gladwin Pines Nursing and Rehabilitation Center
449 Quarter Street, Gladwin, MI 48624 · Gladwin County · 84 certified beds · avg 75 residents/day · certified since Apr 14, 1989
Part of chain: THE PEPLINSKI GROUP (10 facilities, chain avg rating 2.1★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Sep 11, 2025 · F-0684
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 6, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Sep 11, 2025 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 6, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jan 17, 2025 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Feb 25, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Aug 7, 2024 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 20, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jun 15, 2023 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 15, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (30)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Sep 11, 2025 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Sep 11, 2025 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Sep 11, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Sep 11, 2025 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Sep 11, 2025 | F · Potential for harm, facility-wide | The facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program. |
| Sep 11, 2025 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Sep 11, 2025 | E · Potential for harm, repeated | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. |
| Sep 11, 2025 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Sep 11, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Sep 11, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Sep 11, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Sep 11, 2025 | D · Potential for harm, one-off | The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life. |
| Jul 9, 2025 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Jul 9, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Jan 17, 2025 | ▲ G · Actual harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Jan 17, 2025 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint |
| Jan 17, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Aug 7, 2024 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Aug 7, 2024 | F · Potential for harm, facility-wide | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Aug 7, 2024 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 7, 2024 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Aug 7, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Aug 7, 2024 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Aug 7, 2024 | D · Potential for harm, one-off | The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. |
| Aug 7, 2024 | D · Potential for harm, one-off | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| Jun 15, 2023 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jun 15, 2023 | E · Potential for harm, repeated | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. |
| Jun 15, 2023 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Jun 15, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jun 15, 2023 | D · Potential for harm, one-off | The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (8 → 12).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 5 | 1 | G ▲ |
| 2024 | 8 | 1 | G ▲ |
| 2025 | 17 | 3 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
3 fines totaling $144,208, plus 2 Medicare payment denial periods.
| Date | Type | Amount / length |
|---|---|---|
| Sep 11, 2025 | Fine | $71,010 |
| Jan 17, 2025 | Fine | $17,345 |
| Jan 17, 2025 | Payment Denial | 12 days from Feb 13, 2025 |
| Aug 7, 2024 | Fine | $55,853 |
| Aug 7, 2024 | Payment Denial | 8 days from Sep 12, 2024 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Michigan avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.98 | 4.32 | 3.95 | bottom 41% in Michigan; top 40% in the U.S. |
| Registered Nurse hours | 0.85 | 0.84 | 0.69 | top 41% in Michigan; top 24% in the U.S. |
| Weekend total nurse staffing | 3.73 | 3.79 | 3.50 | top 41% in Michigan; top 32% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.64 | 0.49 | 0.48 | top 22% in Michigan; top 20% in the U.S. |
| Total nursing staff turnover (%) | 45.5 | 44.1 | 45.8 | bottom 47% in Michigan; bottom 49% in the U.S. |
| RN turnover (%) | 55.0 | 39.2 | 42.9 | bottom 21% in Michigan; bottom 28% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.33, RN 0.93, weekend 4.05. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: 3/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Ackerman, Ricky | Individual | Direct Ownership Interest | NOT APPLICABLE | 05/01/2016 |
| Baumgarten, Michael | Individual | Direct Ownership Interest | NOT APPLICABLE | 05/01/2016 |
| Peplinski, Todd | Individual | Direct Ownership Interest | NOT APPLICABLE | 05/01/2016 |
| Schade, Jeffery | Individual | Direct Ownership Interest | NOT APPLICABLE | 05/01/2016 |
| Thompson, Brian | Individual | Direct Ownership Interest | NOT APPLICABLE | 05/01/2016 |
| Ackerman, Ricky | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/01/2016 |
| Ackerman, Ricky | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2016 |
| Baumgarten, Michael | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2016 |
| Gladwin Pines Property Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 05/01/2016 |
| Pepera, Christine | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/12/2021 |
| Pepera, Christine | Individual | ADP of the SNF | NOT APPLICABLE | 07/12/2021 |
| Peplinski, Todd | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2016 |
| Plante & Moran PLLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 05/01/2016 |
| Plante & Moran PLLC | Organization | ADP of the SNF | NOT APPLICABLE | 04/15/2025 |
| Potnis, Amarish | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/01/2016 |
| Potnis, Amarish | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2016 |
| Schade, Jeffery | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/01/2016 |
| Schade, Jeffery | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2016 |
| The Peplinski Group INC | Organization | ADP of the SNF | NOT APPLICABLE | 05/01/2016 |
| Thompson, Brian | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/01/2016 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Who is your infection preventionist, and what training do they have?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Gladwin Nursing and Rehabilitation Community | 2.2 mi | Gladwin, MI | ★★★★☆ | 4/5 | |
| Medilodge of Clare | 17.2 mi | Clare, MI | ★★★★★ | 4/5 |
Compare this facility with the 2 closest →
Facility data as of CMS processing date 2026-08-01. CCN 235485.