Grand Oaks Nursing Center
Grand Oaks Nursing Center in Baldwin, MI — inspection on January 29, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 1/28/25 at approximately 3:45 PM, the Nursing Home Administrator (NHA) revealed they only had one other resident complaint about the doctor/podiatrist the day of this incident.
The other resident complained the doctor had an attitude and was rude.
The rest of the residents (approximately 20) seen that day had no concerns.
The NHA further revealed that she had heard from the company the podiatrist works for earlier today and they wanted to know when he could come back into the facility.
The DON stated, I informed them that he would not be welcomed back to our building.
235499 01/29/2026
Grand Oaks Nursing Center 600 Denmark Street Baldwin, MI 49304
Review of the Care Plan for R2 revealed a Focus for:ADL's (Activity of Daily Living) last revised 1/12/26 revealed: TOILETING/ELIMINATION: Foley catheter to drainage.
Maintain drainage bag placement below bladder.
Catheter care with soap and water with AM/PM care and PRN.
Maintain a closed drainage system; report diminished output to the Charge Nurse and any skin integrity concerns.
Avoid dependent loops in the drainage tubing.
Initiated 12/1/25.
Review of the medical record reveals R2 does not have Foley catheter.
Review of the elimination Care Plan for R2 revealed a Focus for: has the potential for altered elimination related to: (R2) has a diagnosis of obstructive reflux uropathy resulting in impaired bladder emptying. A suprapubic catheter is in place to ensure continuous bladder drainage and prevent overdistention, reflux, or renal complications.
Despite adherence to infection prevention protocols, aseptic catheter care and routine monitoring, the presence of an indwelling urinary catheter inherently increases the risk for UTI (urinary tract infection), bacteriuria, and urethral irritation.
This risk is considered unavoidable due to the residents underlying medical condition that necessitates catheter use for bladder management and comfort.
Last revised 10/29/26. No interventions for a suprapubic catheter.
In an interview on 1/29/26 at 12:43 PM, the Director of Nursing (DON) was asked about R2's suprapubic catheter.
The DON reported R2 should have had a T-sponge in place and if the skin surrounding the area was excoriated, staff should start with soap and water to clean the area first and then move up to other options if that was not working.
The DON expects staff to monitor, assess and document findings. If there is anything abnormal, then she would expect a short-term care plan to be in place.
The DON was informed about the conflicting orders for a Foley catheter instead of a suprapubic catheter and the Care Plan reflecting a Foley catheter.
The DON reported that it should not be that way as we discussed the importance of Agency Staff being able to know how to care for a resident based on appropriate orders, care planning, and documentation. In an interview on 1/29/26 at approximately 1:15 PM, the DON reported she followed up with R2 and verified R2 did not have any wounds on his heels. R2's suprapubic catheter site should be documented and monitored.
Any labs for residents are resident specific and depends on how long they were on a medication and the residents' baseline.
Review of R2's Care Plans revealed they are showing incorrect information or missing information pertaining to the resident's current medical status and do not include pertinent interventions per medical orders.
Further review of R2's Care Plans reveals no Care Plan for Chronic Kidney Disease (CKD) for R2, hyperkalemia, hyponatremia, and prostatic hyperplasia.