Grand Oaks Nursing Center

Name: Grand Oaks Nursing Center
Address: 600 Denmark Street, Baldwin, MI, 49304, US
Telephone: 2317454648

600 Denmark Street, Baldwin, MI 49304 · Lake County · 79 certified beds · avg 62 residents/day · certified since Dec 11, 1990

Part of chain: THE PEPLINSKI GROUP (10 facilities, chain avg rating 2.1★)

4/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

4.65

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★★☆4/5 · CMS overall rating: 4/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

All citations in the current public record (23)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
May 6, 2026	D · Potential for harm, one-off	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
May 6, 2026	D · Potential for harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
May 6, 2026	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
May 6, 2026	D · Potential for harm, one-off	The facility did not properly inform residents or their representatives about arbitration agreements — contracts that give up the right to sue in court — including their right to refuse to sign.
May 6, 2026	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jan 29, 2026	E · Potential for harm, repeated	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Jan 29, 2026	D · Potential for harm, one-off	The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Mar 20, 2025	E · Potential for harm, repeated	The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Mar 20, 2025	E · Potential for harm, repeated	The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective.
Mar 20, 2025	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint
Mar 20, 2025	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Mar 20, 2025	D · Potential for harm, one-off	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Mar 20, 2025	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Mar 20, 2025	D · Potential for harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Mar 20, 2025	D · Potential for harm, one-off	The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Mar 20, 2025	D · Potential for harm, one-off	The facility admitted a resident without a doctor's order, or did not make sure each resident stayed under a doctor's ongoing care.
Mar 20, 2025	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Nov 20, 2024	E · Potential for harm, repeated	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Oct 7, 2024	D · Potential for harm, one-off	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
May 23, 2024	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Mar 20, 2024	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Mar 20, 2024	E · Potential for harm, repeated	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Mar 20, 2024	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (10 → 5).

Year	Citations	Worst severity that year
2024	6	F
2025	10	E
2026	7	E

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Michigan avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	4.65	4.32	3.95	top 24% in Michigan; top 19% in the U.S.
Registered Nurse hours	0.56	0.84	0.69	bottom 25% in Michigan; bottom 47% in the U.S.
Weekend total nurse staffing	4.08	3.79	3.50	top 26% in Michigan; top 21% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.28	0.49	0.48	bottom 24% in Michigan; bottom 28% in the U.S.
Total nursing staff turnover (%)	56.0	44.1	45.8	bottom 17% in Michigan; bottom 23% in the U.S.
RN turnover (%)	46.2	39.2	42.9	bottom 36% in Michigan; bottom 42% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.04, RN 0.49, weekend 3.55. Staffing rating: 4/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: 2/5

Who owns this facility

For profit - Individual

Owner / manager	Type	Role	Stake	Since
Ackerman, Amy	Individual	5% or Greater Indirect Ownership Interest	10%	01/01/2012
Ackerman, Ricky	Individual	5% or Greater Indirect Ownership Interest	10%	01/01/2012
Baumgarten, Michael	Individual	5% or Greater Indirect Ownership Interest	10%	01/01/2012
Baumgarten, Therese	Individual	5% or Greater Indirect Ownership Interest	10%	01/01/2012
Peplinski, Sheli	Individual	5% or Greater Indirect Ownership Interest	10%	01/01/2012
Peplinski, Todd	Individual	5% or Greater Indirect Ownership Interest	10%	01/01/2012
Schade, Jeffery	Individual	5% or Greater Indirect Ownership Interest	10%	01/01/2012
Schade, Tamara	Individual	5% or Greater Indirect Ownership Interest	10%	01/01/2012
Thompson, Brian	Individual	5% or Greater Indirect Ownership Interest	10%	01/01/2012
Thompson, Shelly	Individual	5% or Greater Indirect Ownership Interest	10%	01/01/2012
Ackerman, Ricky	Individual	Corporate Officer	NOT APPLICABLE	01/01/2012
Ackerman, Ricky	Individual	Operational/Managerial Control	NOT APPLICABLE	01/01/2012
Ackerman, Ricky	Individual	ADP of the SNF	NOT APPLICABLE	01/01/2012
Holbrook, Gayle	Individual	Operational/Managerial Control	NOT APPLICABLE	11/04/2021
Holbrook, Gayle	Individual	ADP of the SNF	NOT APPLICABLE	11/04/2021
Peplinski, Todd	Individual	Corporate Director	NOT APPLICABLE	01/01/2012
Peplinski, Todd	Individual	Corporate Officer	NOT APPLICABLE	01/01/2012
Plante & Moran PLLC	Organization	Operational/Managerial Control	NOT APPLICABLE	01/01/2012
Plante & Moran PLLC	Organization	ADP of the SNF	NOT APPLICABLE	04/10/2025
Schade, Jeffery	Individual	Corporate Director	NOT APPLICABLE	01/01/2012

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
"How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
"How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
"Is signing an arbitration agreement required for admission, and can we refuse it without affecting my family member's care?"
"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
"Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Corewell Health Reed City Hospital Rehabilitation	16.5 mi	Reed City, MI	★★★★★	5/5

Compare this facility with the 1 closest →

All facilities in Baldwin →

Facility data as of CMS processing date 2026-08-01. CCN 235499.

The Care File

Visit checklist — Grand Oaks Nursing Center

600 Denmark Street, Baldwin, MI 49304 · 2317454648

Health inspection rating 4/5 · CMS overall 4/5· Fines (3y): $0

Questions for the administrator:

☐ "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
☐ "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
☐ "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
☐ "Is signing an arbitration agreement required for admission, and can we refuse it without affecting my family member's care?"
☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
☐ "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 235499 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)