Baldwin, MI

Grand Oaks Nursing Center

3-star overall rating with 3-star inspections with 12 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

600 Denmark Street, Baldwin, MI

(231) 745-4648

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

The Peplinski Group

Operator or chain grouping

Approved since

1990-12-11

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.50

Registered nurse staffing

LPN hours / resident day

0.72

Licensed practical nurse staffing

Aide hours / resident day

2.61

Nurse aide staffing

Weekend hours

3.48

Weekend nurse staffing

RN turnover

70%

Annual RN turnover

Total nurse turnover

62%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	0.7	1.7 1 pts better	1.9 1.2 pts better	Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days	2.0	1.5 0.5 pts worse	1.8 0.2 pts worse	Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.6%	95.0% 4.6 pts better	93.4% 6.2 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	95.0% 5 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury	0.9%	3.1% 2.2 pts better	3.3% 2.4 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms	2.9%	4.1% 1.2 pts better	11.4% 8.5 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight	15.3%	5.5% 9.8 pts worse	5.4% 9.9 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication	15.7%	19.6% 3.9 pts better	19.6% 3.9 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication	17.9%	16.5% 1.4 pts worse	16.7% 1.2 pts worse	Long Stay · 2024Q4-2025Q3
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
Percentage of long-stay residents whose ability to walk independently worsened	16.7%	13.9% 2.8 pts worse	16.3% 0.4 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased	13.0%	11.7% 1.3 pts worse	14.9% 1.9 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.3%	0.9% 0.6 pts better	1.0% 0.7 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection	3.0%	1.7% 1.3 pts worse	1.7% 1.3 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	20.9%	20.4% 0.5 pts worse	19.8% 1.1 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers	5.2%	5.6% 0.4 pts better	5.1% 0.1 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	98.6%	82.8% 15.8 pts better	81.7% 16.9 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit	10.0%	11.5% 1.5 pts better	12.0% 2 pts better	Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication	1.0%	1.3% 0.3 pts better	1.6% 0.6 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	96.3%	79.5% 16.8 pts better	79.7% 16.6 pts better	Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission	14.7%	24.2% 9.5 pts better	23.9% 9.2 pts better	Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-03-20 · Fire 2025-03-20

12 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

2 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2024-03-20 · Fire 2024-03-20

6 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2023-04-05 · Fire 2023-04-05

15 health deficiencies

Top issue: Quality of Life and Care (7 deficiencies)

2 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-03-20

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2025-04-25

E · Potential for more than minimal harm 2025-03-20

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2025-04-25

F · Potential for more than minimal harm 2024-03-20

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2024-04-27

F · Potential for more than minimal harm 2024-03-20

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-04-27

E · Potential for more than minimal harm 2024-03-20

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 2024-04-27

E · Potential for more than minimal harm 2024-03-20

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-04-27

E · Potential for more than minimal harm 2024-03-20

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-04-27

F · Potential for more than minimal harm 2023-04-05

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2023-04-20

F · Potential for more than minimal harm 2023-04-05

K916 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have a battery powered remote alarm panel in a location accessible by operating personnel.

Corrected 2023-04-20

Inspection history

Recent health citations

E · Potential for more than minimal harm 2026-01-29

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2026-03-01

D · Potential for more than minimal harm 2026-01-29

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2026-03-01

E · Potential for more than minimal harm 2025-03-20

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2025-04-25

E · Potential for more than minimal harm 2025-03-20

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2025-04-25

D · Potential for more than minimal harm 2025-03-20

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2025-04-25

D · Potential for more than minimal harm 2025-03-20

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2025-04-25

D · Potential for more than minimal harm 2025-03-20

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2025-04-25

D · Potential for more than minimal harm 2025-03-20

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-04-25

D · Potential for more than minimal harm 2025-03-20

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-04-25

D · Potential for more than minimal harm 2025-03-20

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2025-04-25

D · Potential for more than minimal harm 2025-03-20

F710 · Nursing and Physician Services Deficiencies

Health

Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

Corrected 2025-04-25

D · Potential for more than minimal harm 2025-03-20

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-04-25

E · Potential for more than minimal harm 2024-11-20

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-11-01

D · Potential for more than minimal harm 2024-10-07

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 2024-11-08

D · Potential for more than minimal harm 2024-05-23

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 2024-06-21

F · Potential for more than minimal harm 2024-03-20

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-04-26

E · Potential for more than minimal harm 2024-03-20

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2024-04-26

D · Potential for more than minimal harm 2024-03-20

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-04-26

G · Actual harm 2023-04-05

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2023-05-03

G · Actual harm 2023-04-05

F693 · Quality of Life and Care Deficiencies

Health

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected 2023-05-03

F · Potential for more than minimal harm 2023-04-05

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2023-05-03

F · Potential for more than minimal harm 2023-04-05

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-05-03

E · Potential for more than minimal harm 2023-04-05

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2023-05-03

E · Potential for more than minimal harm 2023-04-05

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-05-03

D · Potential for more than minimal harm 2023-04-05

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2023-05-03

D · Potential for more than minimal harm 2023-04-05

F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected 2023-05-03

D · Potential for more than minimal harm 2023-04-05

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2023-05-03

D · Potential for more than minimal harm 2023-04-05

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2023-05-03

D · Potential for more than minimal harm 2023-04-05

F676 · Quality of Life and Care Deficiencies

Health

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Corrected 2023-05-03

D · Potential for more than minimal harm 2023-04-05

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2023-05-03

D · Potential for more than minimal harm 2023-04-05

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 2023-05-03

D · Potential for more than minimal harm 2023-04-05

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2023-05-03

D · Potential for more than minimal harm 2023-04-05

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2023-05-03

Penalties and ownership

What sits behind the stars

Ownership

Peplinksi Holdings, Inc.

5% Or Greater Direct Ownership Interest · Organization

100% 6 facilities 2012-01-01

Ackerman, Amy