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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
Potential for More Than Minimal Harm

During an interview on 1/28/26 at 11:35 AM, the DON stated, I was pulled out of a meeting by (DOR C) and told that an incident occurred.

Before I could get down the hallway, my Unit Managers (CCC's) were bringing him (doctor/podiatrist) down to my office.

The doctor claimed (Name of R1) assaulted him. He said she hit and kicked him while she was still sitting on the bed, and then he tipped her leg back while she was on the bed. (CNA A) said he saw him shove her onto the bed.

The doctor said she assaulted him, and I did observe some pink on the side of his head, but it went away while we were waiting for the sheriff to show up.

The DON revealed that while waiting for the sheriff to show-up, the Doctor wanted to leave and wanted to know when the sheriff department would get there. He also wanted to continue to see the rest of the residents on his list or leave.

The DON said she told him he had to stay there and he continued to explain why he felt what he did was appropriate.

She stated that he didn't seem to think or act like it was a big deal.

The DON further revealed she did not do a full skin assessment because (R1) would not allow them to and as they were attempting to assess what they could she started getting more upset and agitated.

She then stated that R1 did not have any concerning behaviors receiving care by the doctor prior to this and this was the first time she was aware of a problem.

The DON stated that he (doctor/podiatrist) would go into resident rooms by himself because a lot of the residents he saw were bedbound and more comfortable being seen in their rooms.

The DON stated as result of this incident, all ancillary services will now have a staff member with them.

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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/29/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Grand Oaks Nursing Center

600 Denmark Street Baldwin, MI 49304

SUMMARY STATEMENT OF DEFICIENCIES

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.

Facility ID:

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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