Cycle 1
Health 2024-10-09 · Fire 2024-10-09
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
9 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Gladwin, MI
Gladwin Nursing and Rehabilitation Community
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
3270 Pratt Lake Road, Gladwin, MI
(989) 426-7275
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
40
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Atrium Centers
Operator or chain grouping
Approved since
1977-05-12
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
26 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.72
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.10
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.68
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.58
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.35
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.74
CMS adjusted RN staffing hours
Adjusted total hours
3.82
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,944
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.50
Composite VBP score used to determine payment impact.
Payment multiplier
0.9884
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.14
Baseline 20.41% · Performance 19.98% · Measure score 3.14 · Achievement 3.14 · Improvement 0.78
Healthcare-associated infections
4.59
Baseline 5.91% · Performance 6.46% · Measure score 4.59 · Achievement 4.59 · Improvement 0
Total nurse turnover
4.34
Baseline 55.00% · Performance 45.95% · Measure score 4.34 · Achievement 4.34 · Improvement 2.50
Adjusted total nurse staffing
1.73
Baseline 3.67 hours · Performance 3.57 hours · Measure score 1.73 · Achievement 1.73 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.57% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 74 · Observed rate 16.22% · Lower 95% interval 8.14% |
| Discharge to community | 59.62% |
50.57%
9 pts better
|
No Different than the National Rate · Eligible stays 64 · Observed rate 51.56% · Lower 95% interval 46.91% |
| Medicare spending per beneficiary | 1.22 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 87.18% |
95.27%
8.1 pts worse
|
Numerator 34 · Denominator 39 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 39 |
| Discharge self-care score | 64% |
53.69%
10.3 pts better
|
Numerator 16 · Denominator 25 |
| Discharge mobility score | 44% |
50.94%
6.9 pts worse
|
Numerator 11 · Denominator 25 |
| Pressure ulcers or injuries, new or worsened | 7.69% |
2.29%
5.4 pts worse
|
Numerator 3 · Denominator 39 · Adjusted rate 7.52% |
| Healthcare-associated infections requiring hospitalization | 6.46% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 48 · Observed rate 4.17% · Lower 95% interval 3.65% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 69 |
| Staff flu vaccination coverage | 19.18% |
42%
22.8 pts worse
|
Numerator 14 · Denominator 73 |
| Discharge function score | 60% |
56.45%
3.5 pts better
|
Numerator 15 · Denominator 25 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 22 · Denominator 22 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.6% |
95.0%
2.6 pts better
|
93.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.5% · Q2 100.0% · Q3 96.7% · Q4 100.0% · 4Q avg 97.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.7% |
95.0%
3.3 pts worse
|
95.5%
3.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
3.1%
1.5 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.6% |
4.1%
5.5 pts worse
|
11.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 6.5% · Q3 11.1% · Q4 14.3% · 4Q avg 9.6% |
| Percentage of long-stay residents who lose too much weight | 4.6% |
5.5%
0.9 pts better
|
5.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.6% · Q3 8.0% · Q4 3.8% · 4Q avg 4.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.9% |
19.6%
8.3 pts worse
|
19.6%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 31.0% · Q3 30.8% · Q4 26.9% · 4Q avg 27.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.8% |
16.5%
5.3 pts worse
|
16.7%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 22.7% · Q3 19.0% · Q4 26.1% · 4Q avg 21.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.4% |
13.9%
3.5 pts worse
|
16.3%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.6% |
11.7%
1.1 pts better
|
14.9%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 14.3% · Q3 8.3% · Q4 8.7% · 4Q avg 10.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.1% |
1.7%
2.4 pts worse
|
1.7%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 9.4% · Q3 3.4% · Q4 0.0% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.5% |
20.4%
5.9 pts better
|
19.8%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 13.3% · Q3 13.5% · Q4 3.2% · 4Q avg 14.5% |
| Percentage of long-stay residents with pressure ulcers | 1.8% |
5.6%
3.8 pts better
|
5.1%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 7.8% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 82.2% |
82.8%
0.6 pts worse
|
81.7%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 81.4% · Q2 78.3% · Q3 82.4% · Q4 87.1% · 4Q avg 82.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 29.4% |
11.5%
17.9 pts worse
|
12.0%
17.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.4% · Observed 34.5% · Expected 13.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.3%
0.1 pts worse
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.3% · Q4 3.1% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 67.1% |
79.5%
12.4 pts worse
|
79.7%
12.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 67.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.1% |
24.2%
4.9 pts worse
|
23.9%
5.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.1% · Observed 37.9% · Expected 31.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-09 · Fire 2023-11-09
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-11-15 · Fire 2022-11-15
2 health deficiencies
Top issue: Environmental (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-09
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-11-18
F · Potential for more than minimal harm
2024-10-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-18
F · Potential for more than minimal harm
2024-10-09
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-11-18
F · Potential for more than minimal harm
2024-10-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-18
E · Potential for more than minimal harm
2024-10-09
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-11-18
E · Potential for more than minimal harm
2024-10-09
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-11-18
E · Potential for more than minimal harm
2024-10-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-18
E · Potential for more than minimal harm
2024-10-09
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-10-09
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-11-18
F · Potential for more than minimal harm
2023-11-09
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-04-01
F · Potential for more than minimal harm
2023-11-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-09
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-12-18
F · Potential for more than minimal harm
2023-11-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-01
F · Potential for more than minimal harm
2023-11-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-11-09
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-12-01
F · Potential for more than minimal harm
2022-11-15
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-12-09
F · Potential for more than minimal harm
2022-11-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-12-12
F · Potential for more than minimal harm
2022-11-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-09
F · Potential for more than minimal harm
2022-11-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-12-09
D · Potential for more than minimal harm
2022-11-15
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-12-09
Inspection history
Recent health citations
G · Actual harm
2025-04-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-06
D · Potential for more than minimal harm
2025-04-17
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-05-06
D · Potential for more than minimal harm
2024-12-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-01-13
D · Potential for more than minimal harm
2024-10-09
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-10-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-01
E · Potential for more than minimal harm
2023-11-09
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-12-18
D · Potential for more than minimal harm
2023-11-09
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-12-18
D · Potential for more than minimal harm
2023-11-09
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-12-18
D · Potential for more than minimal harm
2023-11-09
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-12-18
F · Potential for more than minimal harm
2022-11-15
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2022-12-03
E · Potential for more than minimal harm
2022-11-15
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-12-03
Penalties and ownership
What sits behind the stars
Ownership
Atrium Centers, Inc.
5% Or Greater Direct Ownership Interest · Organization
Albright Ross, Susan
Operational/Managerial Control · Individual
Atrium Centers Management LLC
Operational/Managerial Control · Organization
Bailey, Essel
Corporate Director · Individual
Finney, Donald
Corporate Officer · Individual
Lockhart, Dennis
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Gladwin Pines Nursing and Rehabilitation Center
Gladwin, MI
1-star overall rating with 1-star inspections with $73,198 in total fines with 14 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Medilodge of Clare
Clare, MI
5-star overall rating with 4-star inspections with $10,059 in total fines with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
The Villa at West Branch
West Branch, MI
3-star overall rating with 2-star inspections with $170,704 in total fines with 13 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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