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Complaint Investigation

Grand Oaks Nursing Center

January 29, 2026 · Baldwin, MI · 600 Denmark Street
Citations 2
CMS Rating 3/5
Beds 79
Provider ID 235499
Healthcare Facility
Grand Oaks Nursing Center
Baldwin, MI  ·  View full profile →
Inspection Summary

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.

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Inspection Findings

FF0600
Freedom from Abuse, Neglect, and Exploitation Deficiencies

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.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Baldwin, MI, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Grand Oaks Nursing Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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