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
Registered name: Grand Oaks Nursing Center
Baldwin, MI · Medicare-certified · 79 beds
In good standing
For-profitChain member
Data as of July 1, 2026
3 of 5 overall
Grand Oaks in Baldwin, MI has an overall 3-star rating, with 3-star health inspection and quality scores and a 4-star staffing rating. Reported nurse staffing is just below the federal benchmark (4.04 vs. 4.1 hours per resident per day), there were no fines in the last 24 months, and recent inspection citations included pressure ulcer care, feeding-tube care, and food sourcing/storage/serving standards.
Facility ratings
Health inspections
Staffing
4.0438 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 4.0438.
Staffing detail
- Registered nurses
- 0.49
- Licensed practical nurses
- 0.82
- Nurse aides
- 2.73
- Weekend nursing
- 3.55
Hours per resident per day.
Total staff turnover: 56%
Registered nurse turnover: 46%
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Long-stay residents on antipsychotic medication
14.3%23.1%Worsening
Residents with a fall causing major injury
1.7%3.9%Worsening
Residents with pressure ulcers (bedsores)
4.3%2%Improving
Residents with a urinary tract infection
8.3%0%Improving
Residents who lost too much weight
11.1%4.8%Improving
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
17.6%9.8%Improving
Residents whose ability to walk got worse
12.7%4.2%Improving
Long-stay residents on antianxiety or sleep medication
16.7%11.4%Improving
Short-stay residents newly given an antipsychotic
0%0%No change
Residents with a long-term catheter
0%0%No change
Residents with new or worsening incontinence
29.2%16.8%Improving
Residents with depressive symptoms
0%0%No change
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Long-stay residents given the seasonal flu vaccine
—100%—
Long-stay residents given the pneumonia vaccine
100%100%No change
Short-stay residents given the seasonal flu vaccine
—96.3%—
Short-stay residents given the pneumonia vaccine
100%100%No change
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 · 2.1 stars avg
- Occupancy
- 62.2 residents on an average day (79% 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.