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

Chain footprint

10 facilities

Chain averages 3 overall / 2 health / 3 staffing / 4 quality stars

Changed ownership

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

0.50

Registered nurse staffing · state 0.77 · national 0.68

LPN hours / resident day

0.72

Licensed practical nurse staffing · state 0.88 · national 0.87

Aide hours / resident day

2.61

Nurse aide staffing · state 2.38 · national 2.35

Total nurse hours

3.82

All reported nurse hours · state 4.03 · national 3.89

Licensed hours

1.21

RN + LPN hours · state 1.65 · national 1.54

Weekend hours

3.48

Weekend nurse staffing · state 3.52 · national 3.43

Weekend RN hours

0.31

Weekend registered nurse coverage · state 0.49 · national 0.47

Physical therapist

0.02

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.54

CMS adjusted RN staffing hours

Adjusted total hours

4.20

CMS adjusted total nurse staffing hours

Case-mix index

1.25

Higher values indicate more complex resident acuity

RN turnover

70%

Annual RN turnover · state 41% · national 45%

Total nurse turnover

62%

Annual nurse turnover · state 44% · national 46%

SNF VBP

Value-based purchasing

Program rank

10,102

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

21.44

Composite VBP score used to determine payment impact.

Payment multiplier

0.9826

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 19.46% · Performance 21.41% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

4.20

Baseline 6.25% · Performance 6.58% · Measure score 4.20 · Achievement 4.20 · Improvement 0

Total nurse turnover

0.65

Baseline 61.97% · Performance 61.04% · Measure score 0.65 · Achievement 0.65 · Improvement 0

Adjusted total nurse staffing

3.73

Baseline 3.76 hours · Performance 4.14 hours · Measure score 3.73 · Achievement 3.73 · Improvement 1.38

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	12.5%	10.72% 1.8 pts worse	No Different than the National Rate · Eligible stays 52 · Observed rate 19.23% · Lower 95% interval 9.3%
Discharge to community	38.01%	50.57% 12.6 pts worse	No Different than the National Rate · Eligible stays 47 · Observed rate 27.66% · Lower 95% interval 27.03%
Medicare spending per beneficiary	0.81	1.02 0.2 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 34 · Denominator 34
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 34
Discharge self-care score	30.77%	53.69% 22.9 pts worse	Numerator 8 · Denominator 26
Discharge mobility score	19.23%	50.94% 31.7 pts worse	Numerator 5 · Denominator 26
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 34 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	6.58%	7.12% 0.5 pts better	No Different than the National Rate · Eligible stays 27 · Observed rate 3.7% · Lower 95% interval 3.4%
Staff COVID-19 vaccination coverage	2.47%	8.2% 5.7 pts worse	Numerator 2 · Denominator 81
Staff flu vaccination coverage	46.31%	42% 4.3 pts better	Numerator 69 · Denominator 149
Discharge function score	26.92%	56.45% 29.5 pts worse	Numerator 7 · Denominator 26
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly.

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 · Adjusted 0.7 · Observed 0.5 · Expected 1.3 · Used in QM five-star
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 · Adjusted 2.0 · Observed 1.6 · Expected 1.3 · Used in QM five-star
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 · Q1 98.2% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6%
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 · 4Q avg 100.0%
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 · Q1 0.0% · Q2 0.0% · Q3 1.7% · Q4 1.8% · 4Q avg 0.9% · Used in QM five-star
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 · Q1 7.7% · Q2 3.9% · Q3 0.0% · Q4 0.0% · 4Q avg 2.9%
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 · Q1 20.8% · Q2 26.9% · Q3 11.1% · Q4 2.1% · 4Q avg 15.3%
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 · Q1 16.7% · Q2 17.0% · Q3 16.7% · Q4 12.2% · 4Q avg 15.7%
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 · Q1 22.5% · Q2 16.7% · Q3 15.9% · Q4 16.7% · 4Q avg 17.9% · 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	16.7%	13.9% 2.8 pts worse	16.3% 0.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q2 30.2% · Q3 12.7% · Q4 8.0% · 4Q avg 16.7% · Used in QM five-star
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 · Q1 13.3% · Q2 12.0% · Q3 17.6% · Q4 8.5% · 4Q avg 13.0% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.2% · 4Q avg 0.3% · Used in QM five-star
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 · Q1 3.5% · Q2 0.0% · Q3 8.3% · Q4 0.0% · 4Q avg 3.0% · Used in QM five-star
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 · Q1 25.9% · Q2 9.4% · Q3 29.2% · Q4 19.3% · 4Q avg 20.9%
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 · Q1 1.3% · Q2 8.7% · Q3 4.3% · Q4 6.5% · 4Q avg 5.2% · Used in QM five-star
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 · Q1 95.8% · Q2 98.1% · Q3 100.0% · Q4 100.0% · 4Q avg 98.6%
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 · Adjusted 10.0% · Observed 10.0% · Expected 11.2% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.1% · 4Q avg 1.0% · Used in QM five-star
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 · 4Q avg 96.3%
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 · Adjusted 14.7% · Observed 13.3% · Expected 21.6% · Used in QM five-star

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