Grandvue Medical Care: Vaccination Failures - MI
The resident, identified as R36 in the March inspection report, had signed a consent form on June 5, 2024, specifically requesting pneumococcal vaccines "indicated per CDC guidelines, including a PCV20." The facility never administered the vaccine.
On December 3, 2024, nurses documented that R36 was confused with no verbal response to questioning. The resident's temperature spiked to 101.4 degrees Fahrenheit with a heart rate of 122 beats per minute. An on-call provider ordered immediate transfer to the emergency department. R36 was subsequently admitted to the hospital with pneumonia.
Federal inspectors found no physician documentation in R36's electronic medical record indicating any doctor had addressed the resident's vaccine request.
R36 was not alone.
Two other residents at the 1728 S Peninsula Road facility signed similar consent forms requesting CDC-recommended pneumococcal vaccines but never received them, inspectors found. All three residents had previously received older versions of pneumonia vaccines but were eligible for the newer PCV20 vaccine under federal guidelines.
Resident 75, whose representative signed a vaccination consent form on August 8, 2023, had received previous pneumococcal vaccines in 2016 and 2018. The consent form specifically requested "vaccinations if indicated per CDC guidelines, including the PCV20."
The facility's own admission assessment documented that R75's pneumococcal vaccinations were "up to date," yet immunization records showed no PCV20 vaccine was ever administered. Physicians left no documentation that they had considered the vaccine or discussed it with the resident's representative.
Resident 15 signed a consent form on May 8, 2024, with identical language requesting CDC-recommended vaccinations including the PCV20. Like the others, R15 had received older pneumococcal vaccines in 2015 and 2017 but never got the requested newer vaccine.
All three residents met CDC criteria for the supplemental PCV20 vaccine, having previously completed the pneumococcal vaccine series with both PCV13 and PPSV23 vaccines.
The facility's Infection Preventionist confirmed during a March 20 interview that none of the three residents received the PCV20 vaccines "in accordance with their wishes as documented on the vaccine consent forms."
When asked if there was documentation that the vaccinations had been considered, the Infection Preventionist said it was "up to the provider to consider the vaccination and to document in the residents' EMR." The official admitted providers had not documented consideration of PCV20 vaccination for any of the three residents.
CDC guidelines specifically note that nursing home residents face increased risk of exposure to pneumococcal disease. The determination to administer PCV20 vaccines should be "based on a shared clinical decision-making process between a patient and their health care provider," according to federal recommendations.
The CDC guidance explicitly states that increased risk "may occur among people who are living in nursing homes or other long-term care facilities."
Grandvue's own policy, reviewed as recently as June 10, 2024, required offering residents "immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations." The policy mandated that vaccination series "will be offered per current CDC guidelines."
The policy also required documentation showing "the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization" and that "the resident received the pneumococcal immunization or did not receive due to medical contraindication or refusal."
None of the three residents refused the vaccines. Medical records contained no documented contraindications. All three had signed consent forms specifically requesting the vaccinations.
R36's case proved particularly troubling to inspectors. The resident had been cognitively intact upon admission, scoring 15 on the Brief Interview for Mental Status assessment, indicating full mental capacity when signing the vaccine consent form.
The resident's admission assessment in 2024 documented that pneumococcal vaccinations were "up to date," yet immunization records showed the last pneumococcal vaccine was administered in 2015 — nine years before admission to Grandvue.
R75's immunization history showed a similar pattern. The resident had received PCV13 in October 2016 and PPSV23 in June 2018, making them eligible for the supplemental PCV20 vaccine that their representative had specifically requested.
R15's vaccination record showed PCV13 administration in December 2015 and PPSV23 in October 2017. Like the others, R15 met all CDC criteria for the PCV20 vaccine and had explicitly consented to receive it.
The inspection found no evidence that physicians had reviewed any of the three vaccination requests or made clinical decisions about administering the vaccines. Electronic medical records contained no documentation of provider consideration, discussion with residents or families, or clinical reasoning for withholding the requested immunizations.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" to a "few" residents. The finding represents a failure to follow the facility's own vaccination policies and CDC guidelines for pneumococcal disease prevention in long-term care settings.
The timing of R36's pneumonia hospitalization — six months after requesting but not receiving the PCV20 vaccine — underscored the potential consequences of the facility's vaccination failures. R36 remained hospitalized with pneumonia as of the inspection report's completion.
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
- View all inspection reports for Grandvue Medical Care Facility
- Browse all MI nursing home inspections
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 14, 2026 · Our methodology
Grandvue Medical Care Facility in East Jordan, MI was cited for violations during a health inspection on March 20, 2025.
On December 3, 2024, nurses documented that R36 was confused with no verbal response to questioning.
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.
Frequently Asked Questions
- What happened at Grandvue Medical Care Facility?
- On December 3, 2024, nurses documented that R36 was confused with no verbal response to questioning.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in East Jordan, MI, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from Grandvue Medical Care Facility or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 235062.
- Has this facility had violations before?
- To check Grandvue Medical Care Facility's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.