Grandvue Medical Care: Elopement Alarm Gaps - MI
The resident, identified in inspection records only as R23, had not attempted to leave the secured unit in over a year. That should have triggered regular reassessment of whether the alarm remained appropriate. It didn't.
The licensed practical nurse who served as care coordinator told inspectors on the morning of March 20 that she simply hadn't caught it. "It had been at least a year since R23 tried to leave the locked unit," she said. "The residents are assessed quarterly and I did not realize I missed the assessment."
The director of nursing confirmed it. R23 had not tried to leave the facility, the DON acknowledged, and the quarterly alarm assessments had not been completed. The DON said the facility had a policy governing alarm assessments and offered to produce it during the interview.
The facility never did.
When inspectors wrapped up and left the building, no alarm assessment policy had been provided. The facility's broader elopement and wandering policy, last reviewed February 5, 2025, was on hand. It stated that alarms "are not a replacement for necessary supervision" and described a systematic approach to identifying risks, evaluating hazards, and modifying interventions when necessary. What it did not include, apparently, was specific guidance on when and how to assess whether a resident's alarm remained warranted.
The registered nurse who held the combined role of MDS coordinator and assistant director of nursing put the gap plainly. "R23 has not had an elopement incident in over a year," she told inspectors. "There is no need for R23 to have the alarm at this time. R23 should have been assessed quarterly for the alarm as part of the quarterly MDS assessment."
The MDS, or Minimum Data Set, is the standardized assessment tool nursing homes use to track resident condition and care needs. Quarterly completion is routine. That the alarm review was supposed to be folded into that process, and still wasn't done, points to a breakdown in a system that staff described as standard procedure.
Inspectors classified the violation as causing minimal harm, or potential for actual harm, to a few residents. The finding fell under federal standards requiring facilities to ensure residents who are at risk of elopement receive adequate supervision and safety interventions, and that those interventions are regularly evaluated.
Grandvue Medical Care Facility sits on South Peninsula Road in East Jordan, a small city in northern Michigan. The facility operates a locked unit specifically designed for residents who may wander or attempt to leave without understanding the risk to themselves.
The care coordinator said she would conduct a risk assessment for R23's alarm going forward. What the inspection record does not show is how long R23 wore a device that no one had formally evaluated in more than twelve months, or whether that device was still clinically appropriate, or whether anyone had asked.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Grandvue Medical Care Facility from 2025-03-20 including all violations, facility responses, and corrective action plans.
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.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 3, 2026 · Our methodology
Grandvue Medical Care Facility in East Jordan, MI was cited for violations during a health inspection on March 20, 2025.
The resident, identified in inspection records only as R23, had not attempted to leave the secured unit in over a year.
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.