Grandvue Medical Care Facility

F-F770 Grandvue Residents Affected - Few Based on interview and record review, the facility failed to ensure laboratory services were provided to meet

the needs of one Resident (#25) of one resident reviewed for laboratory services. Findings include:

Resident #25

A review of the Electronic Medical Record (EMR) for Resident R25 revealed admission to the facility on [DATE REDACTED] with a primary diagnosis of memory deficit following cerebral infarction (stroke).

Resident R25 had a prosthetic heart valve and was prescribed the anticoagulant warfarin (a blood thinning medication that can result in excessive bleeding and death if given in excessive doses).

A review of the Medscape information on Warfarin revealed the safety and efficacy is dependent on maintaining an INR (International Normalized Ratio, a blood test that measures blood clotting) within a specified target range.

A review of the EMR revealed Resident R25 was transferred to the hospital on [DATE REDACTED], [DATE REDACTED], and [DATE REDACTED] where Resident R25 was determined to have supratherapeutic (exceeding therapeutic limits) INR results.

When Resident R25 was transferred back to the facility after a hospitalization on [DATE REDACTED], the hospital discharge instructions directed, in part: Check INR every 24 hours to monitor downward trend .

A nursing progress note dated [DATE REDACTED] at 1:30 PM documented the provider was made aware of the hospital specifying daily INRs. The note indicated concern the facility did not have lab availability on Saturdays or Sundays. The response from the provider was to allow Resident R25 to return to the facility with INRs to be drawn on Wednesday ([DATE REDACTED]), Friday ([DATE REDACTED]), and Monday ([DATE REDACTED]) and to hold warfarin through Wednesday [DATE REDACTED].

Review of the EMR demonstrated the laboratory draw was obtained on [DATE REDACTED]. The laboratory report read Test not performed. Specimen submitted in expired/outdated collection device. The laboratory report documented the specimen was obtained on [DATE REDACTED] but not reported until [DATE REDACTED].

Resident R25 was transferred to the hospital Emergency Department on [DATE REDACTED] and the hospital obtained an INR.

The EMR of Resident R25 revealed laboratory results were not reported for at least 24 hours after laboratory specimens were collected. The results of an INR collected on [DATE REDACTED] was reported to the facility on [DATE REDACTED].

A laboratory report containing critical results was obtained on [DATE REDACTED] and reported to the facility [DATE REDACTED]. The results of an INR collected on [DATE REDACTED] was reported to the facility on [DATE REDACTED]. A laboratory result collected on [DATE REDACTED] was reported on [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 17 235062 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235062 B. Wing 03/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Grandvue Medical Care Facility 1728 S Peninsula Road East Jordan, MI 49727

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0770 The Clinical Care Coordinator (Registered Nurse (RN) N) was interviewed on [DATE REDACTED] at 10:12 AM. RN N expressed challenges with the facility's provider of laboratory services. RN N said the lab was not open or Level of Harm - Minimal harm or available when needed and said the laboratory was closed on weekends, so they were unable to obtain potential for actual harm laboratory specimens on weekends. RN N said the laboratory courier required all specimens to be ready for pick-up by 4:00 PM Monday through Friday so evening lab draws were an impossibility. RN N explained the Residents Affected - Few lab specimens were picked up at 4:00 PM and taken to (the name of a city approximately 50 miles from the facility) to then be shipped to another state in the USA to conduct the testing. RN N asserted, I don't know how that's feasible! I've had heated [NAME] about this lab. RN N confirmed the facility is not notified of lab results until the next day or several days later.

The Assistant Director of Nursing (ADON) was interviewed on [DATE REDACTED] at 9:23 AM. The ADON said the facility obtained a contract with a new laboratory services provider about a year ago. The ADON said the facility experienced many issues and concerns with the new laboratory provider, and management was aware of the nurses' concerns with the new provider of laboratory services.

The policy titled Laboratory and Ancillary Medical Services dated as reviewed [DATE REDACTED] read, in part: . It is the policy of [name of facility redacted] to provide laboratory and ancillary medical services . Laboratory services will be provided by a contracted laboratory. Emergency and after hours services will be provided .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 17 235062 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235062 B. Wing 03/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Grandvue Medical Care Facility 1728 S Peninsula Road East Jordan, MI 49727

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Level of Harm - Minimal harm or 49735 potential for actual harm Based on interview and record review, the facility failed to ensure the Quality Assurance and Performance Residents Affected - Many Improvement (QAPI) committee met at least once per quarter with the required committee members resulting

in the potential for quality-of-care concerns for all 93 residents in the facility.

Findings include:

A review of the facility QAPI sign in sheets on 3/30/25 at 11:00 a.m., revealed the following:

Meetings were held on4/17/24, 5/15/24, 6/19/24, 7/17/24, 10/16/24, 11/20/24, 12/18/24, 1/15/25, and 2/19/25.

The meeting held on 7/17/24: The Medical Director or designee did not attend.

The facility did not have a QAPI meeting in August 2024 or September 2024.

The Medical Director or designee, who is a required committee member, did not attend the QAPI meeting

during the quarter of July, August, and September.

During an interview on 3/20/25 at 11:26 a.m., the Director of Nursing (DON) reported she was unaware the Medical Director did not attend the meeting and offered to provide proof the Medical Director did attend via zoom for the 7/17/24 meeting. The missing attendance record was not provided by survey exit on 3/20/25 at 2:00 p.m.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 17 235062 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235062 B. Wing 03/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Grandvue Medical Care Facility 1728 S Peninsula Road East Jordan, MI 49727

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49310 potential for actual harm

F-F883 Grandvue Residents Affected - Few Based on interview and record review, the facility failed to administer recommended pneumococcal vaccinations or document the clinical reasons for withholding the pneumococcal vaccinations in three Residents (#36, #75, and #15) of five residents reviewed for immunizations.

Findings include:

Resident #36 (Resident R36)

A nurse progress notes in the EMR (Electronic Medical Record) on 12/3/24 documented Resident R36 was confused with no verbal response to questioning. Resident R36 had a temperature of 101.4 degrees Fahrenheit and a heart rate of 122 beats per minute. The on-call provider was notified and ordered Resident R36 transferred to the Emergency Department (ED) for evaluation. Resident R36 was subsequently admitted to the hospital with Pneumonia.

A review of the EMR for Resident R36 revealed an [AGE] year-old resident admitted to the facility on [DATE REDACTED]. An admission Minimum Data Set (MDS) assessment dated [DATE REDACTED] documented a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident R36 was cognitively intact on admission. The MDS documented the pneumococcal vaccinations for Resident R36 were up to date.

A vaccination consent form signed by Resident R36 on 6/5/24 documented Resident R36 wished to receive the pneumococcal vaccines indicated per CDC (Centers for Disease Control) guidelines, including a PCV20 (type of pneumococcal vaccine).

An immunization report for Resident R36 was reviewed on 3/20/25 and revealed Resident R36 received the PCV13 vaccination

on 5/18/15 and a PPSV23 vaccination on 10/31/07. No further pneumococcal vaccinations were administered to Resident R36, including the PCV20 recommended by the CDC and requested on the consent form signed by Resident R36.

There was no physician's documentation in the Electronic Medical Record (EMR) for Resident R36 indicating the physician addressed the request for administration of PCV20 for Resident R36.

Resident #75 (Resident R75)

Resident R75 was an [AGE] year-old resident admitted to the facility on [DATE REDACTED]. A vaccination consent form was signed by the resident representative on 8/8/23 requesting vaccinations if indicated per CDC guidelines, including the PCV20. An admission MDS dated [DATE REDACTED] documented the pneumococcal vaccinations for Resident R75 were up to date.

An immunization report for Resident R75 was reviewed on 3/20/25 and revealed Resident R75 received PCV13 on 10/5/16 and PPSV23 on 6/1/18. No further pneumococcal vaccinations had were administered to Resident R75, including the PCV20 recommended by the CDC and as requested on the consent signed by the resident representative of Resident R75.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 17 235062 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235062 B. Wing 03/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Grandvue Medical Care Facility 1728 S Peninsula Road East Jordan, MI 49727

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 The EMR of Resident R75 did not contain physician documentation indicating the physician had considered the PCV20 for Resident R75. No documentation by the physician could be found that the physician had discussed the Level of Harm - Minimal harm or PCV20 with the resident representative of Resident R75. potential for actual harm Resident #15 (Resident R15) Residents Affected - Few Resident R15 was a [AGE] year-old resident admitted to the facility on [DATE REDACTED]. An MDS assessment dated [DATE REDACTED] documented a BIMS of 14 indicating Resident R15 was cognitively intact. The MDS documented the pneumococcal vaccination for Resident R15 was up to date.

A vaccination consent form was signed by Resident R15 on 5/8/24 requesting to receive vaccinations if indicated per CDC guidelines, including the PCV20.

An immunization report for Resident R15 was reviewed on 3/20/25 and revealed Resident R15 received the PCV13 on 12/11/15 and the PPSV23 on 10/6/17. No further pneumococcal vaccinations had been administered to Resident R15, including

the PCV20 recommended by the CDC and requested by Resident R15 on the consent.

There was no physician's documentation in the Electronic Medical Record (EMR) of Resident R15 indicating the physician addressed the request for administration of PCV20 for Resident R15.

The Infection Preventionist (IP) was interviewed on 3/20/25 at approximately 11:00 AM. The IP confirmed Resident R36, Resident R75, and Resident R15 did not receive the PCV20 in accordance with their wishes as documented on the vaccine consent forms. The IP was asked if there was any documentation that the vaccinations had been considered for administration. The IP said it was up to the provider to consider the vaccination and to document in the residents' EMR. The IP admitted the provider had not documented consideration of vaccination with PCV20 for Resident R36, Resident R75, or Resident R15.

The CDC pneumococcal vaccine recommendations PCV20 or PCV21 Vaccination for Adults 65 or Older (www.cdc.gov/vaccines/hcp/admin/downloads/job-aid-SCDM-pneumococcal-508.pdf) includes, in part:

Adults [AGE] years of age or older have the option to receive supplemental PCV20 or PCV21 (not both) if

they previously completed the pneumococcal vaccine series with both PCV13 and PPSV23 and meet the following criteria:

1. Previously received one dose of PCV13 (but not PCV15, PCV20, or PCV21) at any age, and

2. Previously received all recommended doses of PPSV23 (including 1 dose of PPSV23 at or after [AGE] years of age)

The determination to administer PCV20 or PCV21 is based on a shared clinical decision-making (SCDM) process between a patient and their health care provider . Consider: Increase risk of exposure to PCV20 or PCV21 serotypes [variations of a virus] may occur among people who are living in: Nursing homes or other long-term care facilities .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 17 235062 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235062 B. Wing 03/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Grandvue Medical Care Facility 1728 S Peninsula Road East Jordan, MI 49727

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 The policy titled IP Pneumococcal Vaccine (Series) dated as reviewed 6/10/24 documented in part: . It is the policy of [the facility] to offer our residents immunization against pneumococcal disease in accordance with Level of Harm - Minimal harm or current CDC guidelines and recommendations . A series of vaccinations will be offered per current CDC potential for actual harm guidelines . The resident's medical record must include documentation that indicates at a minimum, the following: a. The resident or resident's representative was provided education regarding the benefits and Residents Affected - Few potential side effects of pneumococcal immunization. b. The resident received the pneumococcal immunization or did not receive due to medical contraindication or refusal .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 17 235062