Grand Oaks Nursing Center: Care Plan Failures - MI
The resident, identified in inspection records only as R2, has a suprapubic catheter placed to manage a condition that prevents his bladder from emptying properly. He told inspectors he had survived sepsis from a catheter infection in the past and, more recently, had experienced painful swelling in his groin. He attributed the raw skin to dryness. The care plan said something else was supposed to be happening: daily cleansing of the site and a T-sponge applied every day shift to protect the skin. That order had been discontinued January 11, with no documented follow-up on the wound left behind.
The care plan itself was wrong in a more basic way. It listed a Foley catheter, an internal device threaded through the urethra, not the suprapubic catheter the resident actually has. The two require different care. Agency staff reading that plan would have had no accurate instructions for the device in front of them.
The Director of Nursing, told about the discrepancy during the inspection, said it should not be that way and acknowledged that agency staff depend on accurate orders and care plans to know how to treat a resident. She said she expected staff to monitor, assess, and document anything abnormal, and that a short-term care plan should have been in place.
Inspectors found the problems ran deeper than one wrong device. R2's care plans contained no documentation for his chronic kidney disease, hyperkalemia, hyponatremia, or an enlarged prostate, all active diagnoses with no corresponding plan or interventions anywhere in his record.
The man who lifted his shirt to show inspectors the irritated skin around his catheter had already been through sepsis once.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Grand Oaks Nursing Center from 2026-01-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 3, 2026 · Our methodology
Grand Oaks Nursing Center in Baldwin, MI was cited for violations during a health inspection on January 29, 2026.
He told inspectors he had survived sepsis from a catheter infection in the past and, more recently, had experienced painful swelling in his groin.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.