Grandvue Medical Care: Repositioning Plan Gaps - MI
Nobody had written down how often.
Inspectors from the Centers for Medicare and Medicaid Services visited Grandvue Medical Care Facility on March 20, 2025, and found that R53's bedside care plan report contained no information on how frequently she should be repositioned or how often weight should be offloaded from her wound. The comprehensive care plan, initiated in April 2024 after a history of pressure ulcer development linked to immobility, age-related fragility, and anti-platelet therapy, carried a single intervention: encourage repositioning throughout the day and night if you see that the resident has not done so herself.
The problem was that R53 could not do so herself. She was documented as dependent for significant position changes. The care plan had never been updated to reflect that.
By the time inspectors arrived, R53 had developed a Kennedy ulcer, a specific type of pressure wound that can appear rapidly in people nearing the end of life. That finding was also absent from her care plan. No intervention had been added. No repositioning schedule had been set.
The Nursing Care Coordinator, a registered nurse identified in the report as RN S, sat down with inspectors at 9:36 that morning and reviewed R53's current care plan on the spot. She confirmed it had not been updated to reflect the Kennedy ulcer. She confirmed it contained no intervention requiring staff to turn and reposition R53 at least every two hours. Then she confirmed that repositioning every two hours was exactly what R53 should have been receiving, both for comfort and to reduce the risk of new wounds.
That gap, between what the care plan said and what the resident needed, is what inspectors cited.
The facility's own care planning policy, revised as recently as February 19, 2025, a month before the inspection, states that a comprehensive care plan must describe, at a minimum, the services to be furnished to help a resident attain or maintain their highest practicable physical, mental, and psychosocial well-being. Inspectors noted the policy. They also noted R53's care plan did not meet it.
The violation was cited at the minimal harm level, meaning inspectors did not find evidence that R53 had suffered additional injury directly traceable to the documentation failure. But the absence of a written repositioning schedule carries real consequences in a skilled nursing setting. Staff turning R53 depend on the care plan to know when she was last moved and when she needs to be moved again. Without that record, the two-hour standard becomes informal, dependent on whoever happens to notice, subject to the interruptions of any busy shift.
Pressure wounds in immobile residents are not unpredictable events. They develop when skin and underlying tissue are compressed against a surface long enough to cut off circulation. The two-hour repositioning interval exists because that window is roughly how long tissue can tolerate sustained pressure before damage begins. For a resident already carrying an open wound and a history of ulcer development, the margin for error is narrower still.
R53's care plan told staff to encourage her. It did not tell them when to act when she couldn't.
Grandvue Medical Care Facility is located at 1728 South Peninsula Road in East Jordan, a small city in northern Michigan. The inspection was completed March 20, 2025. CMS rated the deficiency as affecting a few residents, with minimal harm.
The care plan, as of the morning inspectors reviewed it, still had no repositioning schedule. RN S confirmed that, too.
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 4, 2026 · Our methodology
Grandvue Medical Care Facility in East Jordan, MI was cited for violations during a health inspection on March 20, 2025.
Nobody had written down how often.
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.