Resident 25 had survived a stroke and lived with a prosthetic heart valve. The combination required warfarin, a blood-thinning medication that prevents clots but can cause fatal bleeding if doses climb too high. Doctors monitor warfarin patients with INR tests that measure how quickly blood clots.
The resident was hospitalized three separate times with dangerously high INR levels that exceeded safe therapeutic limits.
When the resident returned from the hospital in late winter, discharge instructions were explicit: "Check INR every 24 hours to monitor downward trend." The hospital had documented supratherapeutic INR results, meaning the blood was too thin and bleeding risk was severe.
A nursing progress note from 1:30 PM that day captured the facility's dilemma. Staff contacted the provider about the daily INR requirement. The nurse documented concern that the facility "did not have lab availability on Saturdays or Sundays."
The provider's response revealed the system's limitations. Instead of daily monitoring as the hospital ordered, blood draws would happen Wednesday, Friday, and Monday. The warfarin would be held through Wednesday.
But even that reduced schedule failed.
The Wednesday blood draw produced no results. The laboratory report stated: "Test not performed. Specimen submitted in expired/outdated collection device." The blood had been drawn on Wednesday but the failed test wasn't reported until Friday.
The resident was transferred to the hospital emergency department that Friday. Hospital staff obtained the INR test immediately.
Federal inspectors found a pattern of dangerous delays throughout the resident's care. Laboratory results consistently arrived at least 24 hours after specimens were collected, sometimes longer. An INR collected on one date was reported two days later. Critical results obtained on a Tuesday weren't reported until Thursday. Another INR drawn on a Friday arrived the following Monday.
For a medication like warfarin, where blood levels can shift rapidly and cause death within hours, such delays eliminate the possibility of timely intervention.
The Clinical Care Coordinator, a registered nurse identified as RN N, explained the laboratory contractor's restrictions during an interview on March 20. The lab was closed weekends. All specimens had to be ready for pickup by 4:00 PM Monday through Friday, making evening blood draws impossible.
"The lab specimens were picked up at 4:00 PM and taken to [a city approximately 50 miles from the facility] to then be shipped to another state in the USA to conduct the testing," RN N told inspectors.
She called the arrangement unfeasible. "I don't know how that's feasible! I've had heated [discussions] about this lab."
RN N confirmed the facility received no notification of laboratory results until the next day or several days later. The system created gaps that could prove fatal for residents requiring immediate medical intervention based on test results.
The Assistant Director of Nursing said management was aware of the nurses' concerns. The facility had contracted with the new laboratory services provider about a year earlier, and staff experienced "many issues and concerns" with the arrangement.
Despite these documented problems, the facility's own policy promised different service. The Laboratory and Ancillary Medical Services policy, reviewed in March, stated the facility would "provide laboratory and ancillary medical services" through a contracted laboratory, with "emergency and after hours services" available.
The policy language suggested capabilities the actual contractor couldn't deliver.
Federal inspectors also found the facility failed to maintain required quality oversight meetings. The Quality Assurance and Performance Improvement committee, which monitors patient care and safety issues, missed meetings entirely during August and September 2024.
When the committee did meet in July 2024, the Medical Director failed to attend. Federal regulations require the Medical Director's participation in quarterly QAPI meetings to ensure physician oversight of care quality.
The Director of Nursing told inspectors she was unaware the Medical Director had missed the meeting. She offered to provide proof the Medical Director attended via Zoom, but no documentation was provided by the end of the inspection.
Between April 2024 and February 2025, the facility held nine QAPI meetings. The gaps in August and September meant the Medical Director had no documented participation during the entire third quarter of 2024, when quality oversight was most needed.
The inspection also revealed incomplete vaccination policies, though details of that violation were not fully documented in the available report.
Grandvue Medical Care Facility serves 93 residents on South Peninsula Road in East Jordan, a small community in northern Michigan. The facility's laboratory problems affected patient safety at the most critical moments, when blood chemistry changes could mean the difference between recovery and death.
For Resident 25, the combination of a stroke history, prosthetic heart valve, and blood-thinning medication created a narrow margin for error. The laboratory delays eliminated that margin entirely, forcing repeated hospitalizations that might have been prevented with timely test results and appropriate medication adjustments.
The resident's case illustrates how administrative failures in laboratory services can directly threaten lives, particularly for elderly patients with complex medical conditions requiring precise monitoring and rapid response to changing test results.
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
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