Grandvue Medical Care: Transfer Notice Failures - MI
The resident, identified in inspection records only as R15, was admitted to Grandvue Medical Care Facility with acute pulmonary edema, a condition that can deteriorate quickly and requires close monitoring. She was transferred to the hospital on February 12, February 17, February 27, and March 11, 2025. According to inspectors who reviewed her electronic medical record, none of the transfer paperwork included the reason for any of those trips. And no written notification of transfer was ever sent to R15 or her representative on any of those four occasions.
When inspectors asked the Assistant Director of Nursing about written transfer notifications on the morning of March 20, she handed over bed hold information instead. That is a different document entirely, one that addresses whether a resident's room will be held during a hospital stay. It says nothing about why a resident is being transferred, what the facility expects to happen, or what rights the resident has during the process.
A policy was requested. What followed made the situation harder to explain, not easier.
The Director of Nursing, also present during a follow-up interview that same morning, said flatly that the facility had not issued written transfer notifications to residents or their representatives. The Assistant Director of Nursing then produced an undated internal procedure document. It described the process in plain terms: before a transfer or discharge, the facility must provide written notice to the resident or their representative. A social worker or designee completes the form. It gets mailed as soon as practicable. When a signed copy comes back, it goes into the resident's chart.
The Director of Nursing then produced the actual form the procedure referenced, a document titled Notice of Resident Transfer or Discharge. It was blank. It had never been filled out for R15, or apparently for any other resident who had been hospitalized.
When the Director of Nursing was asked again whether these forms had been completed for residents who were transferred, she confirmed they had not.
The Assistant Director of Nursing offered one more detail. The form, she said, used to be used. She could not explain why the facility had stopped.
That answer, or the absence of one, is what the inspection record leaves behind. Grandvue had a written procedure that required the forms. It had the forms themselves. At some point, staff stopped completing them, and by March 2025, no one in nursing leadership could account for when that happened or why.
For R15, that meant four hospitalizations with no written record of why she was being sent, no formal notice to whoever was responsible for her care decisions, and no documentation trail for the transfers beyond the dates themselves. A resident with a serious cardiac and pulmonary condition, moved in and out of the facility repeatedly over the span of a month, with her family receiving nothing on paper each time she left.
The violation was cited at a level of minimal harm or potential for actual harm, affecting some residents. Inspectors did not document that any resident suffered a direct medical consequence from the missing paperwork. What the record does not resolve is what R15's representative understood about those four transfers, what questions went unasked because no written notice arrived, or whether anyone at home knew what to watch for when she came back.
The Assistant Director of Nursing could not explain why the facility had stopped. Neither could the Director of Nursing. The forms were sitting in a drawer somewhere, blank, while a woman with fluid in her lungs made four trips to the hospital in twenty-seven days.
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.
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Last verified: November 2, 2026 · Our methodology
Grandvue Medical Care Facility in East Jordan, MI was cited for violations during a health inspection on March 20, 2025.
She was transferred to the hospital on February 12, February 17, February 27, and March 11, 2025.
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.