The nursing home failed to provide proper pressure ulcer care and failed to prevent new pressure sores from developing. Cited April 2023 — isolated incident, actual harm.
View the original federal record
F-Tag 686 — 42 CFR §483.25(b) — S/S: G
Nursing home report
Grand Oaks Nursing Center
Baldwin, MI · Medicare-certified · 79 beds
In good standing
For-profitChain member
3 of 5 overall
Grand Oaks Nursing Center in Baldwin, MI has a 3-star overall rating, with 3-star health inspection and staffing ratings and 4-star quality measures. It reported 3.93 nurse staffing hours per resident per day, slightly below the federal benchmark of 4.1, had $0 in fines over the last 24 months, and recent inspection citations included pressure ulcer care, feeding tube care, and food handling standards.
Facility ratings
Health inspections
Staffing
3.9341 hrs/resident/day
Quality measures
Last inspection: January 29, 2026Penalties, last 24 months: $0
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 3.9341.
Staffing detail
- Registered nurses
- 0.57
- Licensed practical nurses
- 0.66
- Nurse aides
- 2.71
- Weekend nursing
- 3.54
Hours per resident per day.
Total staff turnover: 62%
Registered nurse turnover: 64%
Resident outcomes
How often residents experience these outcomes, with the direction over the past year.
Long-stay residents on antipsychotic medication
16%Worsening
Residents with a fall causing major injury
1.7%Worsening
Residents with pressure ulcers (bedsores)
6.3%Improving
Residents with a urinary tract infection
2.6%Worsening
Residents who lost too much weight
10.5%Improving
Residents who were physically restrained
0%Steady
Residents needing more help with daily activities
13%Worsening
Residents whose ability to walk got worse
16.3%Improving
Show all measures
Long-stay residents on antianxiety or sleep medication
15.8%Steady
Short-stay residents newly given an antipsychotic
0.9%Steady
Residents with a long-term catheter
0.3%Steady
Residents with new or worsening incontinence
20.8%Worsening
Residents with depressive symptoms
1%Improving
Long-stay residents given the seasonal flu vaccine
100%Steady
Long-stay residents given the pneumonia vaccine
100%Steady
Short-stay residents given the seasonal flu vaccine
96.3%Steady
Short-stay residents given the pneumonia vaccine
98.8%Worsening
What the inspectors found
The home failed to make sure feeding tubes were used only when medically needed and that residents with feeding tubes received proper care. Cited April 2023 — isolated incident, actual harm.
View the original federal record
F-Tag 693 — 42 CFR §483.25 — S/S: G
The home failed to make sure food was safely sourced, stored, prepared, and served according to professional standards. Cited March 2024 — widespread issue, potential for harm.
View the original federal record
F-Tag 812 — 42 CFR §483.60(i) — S/S: F
The home failed to provide enough nursing staff each day and ensure a licensed nurse was in charge on every shift. Cited April 2023 — widespread issue, potential for harm.
View the original federal record
F-Tag 725 — 42 CFR §483.35 — S/S: F
The nursing home failed to provide appropriate treatment and care according to residents' orders, preferences, and goals. Cited January 2026 — limited pattern, potential for harm.
View the original federal record
F-Tag 684 — 42 CFR §483.25 — S/S: E
Recent history
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 2 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 10 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
Operator & ownership
- Ownership
- For profit - Corporation
- Chain
- Part of THE PEPLINSKI GROUP · 10 homes · 2.5 stars avg
- Occupancy
- 60.1 residents on an average day (76% of 79 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 35 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.