Grandvue Medical Care Facility
Grandvue Medical Care Facility in East Jordan, MI — inspection on March 20, 2025.
Found 10 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
2/27/25, and 3/11/25.
The documents Notification of Transfer and Bed Hold Authorization did not reveal the reason for the transfers to the hospital for R15 on these dates.
The Assistant Director of Nursing (ADON) was interviewed on 3/20/25 at 9:18 AM.
The ADON was asked if the facility had written notifications of transfer for residents and resident representatives.
The ADON provided bed hold information but did not provide written notifications of transfer. A policy was requested.
The ADON and Director of Nursing (DON) were interviewed on 3/20/25 at 9:50 AM.
The DON said there were no written notifications of transfer issued to residents or resident representatives.
The ADON said the facility had a documented procedure and provided an undated document Notice of Resident Transfer of Discharge Process.
The document read, in part: .
Notice Requirements Before Transfer/Discharge, the facility must provide written notice to any Resident or Resident Representative . 3.
The Social Worker/designee will complete the Notice of Resident Transfer or Discharge and, as soon as is practicable, will mail said notice .
When a signed notice is returned, it will then be placed in the Resident's hard chart .
The DON was queried regarding the form referenced in the written procedure.
The DON provided a blank copy of a form titled Notice of Resident Transfer or Discharge.
The form included the necessary written requirements for transfers.
The DON was again asked if the forms for written notification of transfers had been completed for the residents who had been transferred to the hospital.
The DON reiterated the forms had not been completed.
The ADON said the form used to be used but could not explain why the facility had stopped providing written notifications of transfer.
235062 03/20/2025
Grandvue Medical Care Facility 1728 South Peninsula Road East Jordan, MI 49727
During an interview on 3/20/25 at 10:15 a.m., LPN/Care Coordinator I stated, It had been at least a
realize I missed the assessment .
During an interview on 3/20/25 at 10:29 a.m., the DON acknowledged R23 should be assessed quarterly for the [Name Brand] alarm and R23 had not tried to leave the facility.
The DON reported the facility had a policy on the alarm assessment which was requested at the time of this interview.
During an interview on 3/20/25 at 10:48 a.m., Registered Nurse/MDS/Assistant Director of Nursing (RN/MDS/ADON) J stated, R23 has not had an elopement incident in over a year .there is no need for [R23] to have the [Name Brand] alarm at this time .R23 should have been assessed quarterly for the [Name Brand] alarm as part of the quarterly MDS assessment .
Review of facility policy titled Elopement and Wandering Resident last reviewed 2/5/25, read in part .Alarms are not a replacement for necessary supervision .[Facility name] shall establish and utilize a systematic approach to monitoring and managing residents including identification and assessment .evaluation and analysis of hazards and risks .and monitoring for effectiveness and modifying interventions when necessary .
A facility policy regarding the assessment or use of alarms was not provided upon exit of the facility on 2/20/25 at 2:00 p.m.
235062 03/20/2025
Grandvue Medical Care Facility 1728 South Peninsula Road East Jordan, MI 49727
During an interview on 3/20/2025 at 9:36 a.m., Nursing Care Coordinator and Registered Nurse (RN) S reviewed R53's current care plan and confirmed R53's care plan was not updated to reflect the presence of the Kennedy ulcer and did not include an intervention to turn and reposition R53 at least every two hours for comfort and to attempt to prevent new wounds from forming. RN S confirmed R53 should be repositioned at least every two hours.
Review of the facility policy titled, Baseline Care Planning and Resident Centered Care Planning, revised 2/19/2025, revealed the following: The comprehensive care plan will describe, at a minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.
235062 03/20/2025
Grandvue Medical Care Facility 1728 South Peninsula Road East Jordan, MI 49727
Review of the MAR revealed the amoxicillin was not administered to R15.
The amoxicillin order was
A nursing progress note dated [DATE] at 8:45 AM documented the provider was notified R15 had not received any antibiotics since returning from the hospital after the inpatient stay for urosepsis.
The note revealed an on-call provider was contacted on [DATE] and [DATE] but the on-call provider was unable to access R15's chart or receive the fax of the hospital discharge.
The nursing progress note of [DATE] at 8:45 AM documented, in part: .Today I'm concerned [R15] is becoming septic again AEB [As Evidenced By]: lethargic, confused with inability to answer questions .rhonchus lung sounds .RR [respiratory rate] 40, HR [heart rate] 100 .indwelling foley catheter shows blood clots, sediment, and milky/pink colored urine .Concerns for rebound sepsis vs. heart failure fluid overload or both The note documented the provider's response was to send R15 to the ED.
R15 was transferred back to the ED and admitted to the hospital on [DATE] for Urosepsis.
Review of a nursing progress note dated [DATE] at 4:35 PM revealed the provider who discharged R15 from the hospital on [DATE] contacted the facility regarding R15 not receiving amoxicillin as prescribed.
The note documented, in part: .I let [hospital provider] know we were not able to get any further antibiotic recommendations from our telehealth on call providers Saturday [[DATE]] and Sunday [[DATE]]. He stated that in the future if there are problems like this to please contact the hospitalist on call at the hospital .
R15 returned to the facility on [DATE] and was subsequently placed on comfort measures. R15 expired [DATE].
The DON and MD were interviewed on [DATE] at 1:00 PM.
The DON said R15 returned to the facility with orders for amoxicillin but R15 was allergic to penicillin.
The MD said he was not notified of R15 not receiving amoxicillin as prescribed by the hospital provider.
The MD said the nurse practitioner was notified on [DATE] and assessed R15.
The nurse practitioner ordered R15 sent to the ED.
Neither the MD nor DON provided an explanation why the medical director or hospital was not notified when the on-call provider failed to prescribe a different antibiotic when the allergy was identified.
235062 03/20/2025
Grandvue Medical Care Facility 1728 South Peninsula Road East Jordan, MI 49727
Review of policy titled, Unused Medications, Disposal of, dated 10/16/24, read in part, Policy: It is the policy of (facility name) that all unused medications will be disposed of safely and legally .DEA (Drug Enforcement Administration) controlled substances: 1. DEA controlled substance medication (narcotic) cannot be returned to the pharmacy .2.
Two of the following personnel types must be present to witness destruction: a.
Director of Nursing b. RN Care Coordinator c.
Neighborhood Nurse d.
Registered Pharmacist e.
Certified Pharmacy Technician f. RN or LPN (Licensed Practical Nurse) Consultant Nurse employed by the pharmacy 3.
Controlled medications are destroyed via the Drug Buster Drug Disposal System .
Review of policy titled, Labeling of Medications and Biologicals, dated 10/23/24, read in part, Policy: It is the policy of (facility name) to ensure all medications and biologicals used in the facility will be labeled in accordance with current guidance .
Review of facility document titled, Insulin Storage Recommendations, dated 2022, read in part, .Cartridges/Pens .insulin lispro and insulin glargine pen, opened up to 28 days .
Review of facility document titled, Medication Storage and Labeling, undated, read in part, .Medication Carts .All opened medications are labeled with an open date and an expiration date.
The expiration date may be the circled manufacturer expiration .Insulin Pens .Verify open date and expiration date .
Review of facility document titled, Medication Storage Audit, undated, read in part, Drugs and biologicals are correctly/securely stored .7. DC'd (discontinued) and/or expired meds removed .11.
Medications have expiration dates .
Review of policy titled, Medication Storage, dated 10/30/24, read in part, Policy: It is the policy of (facility name) to ensure all medications will be stored in the medication cart and/or medication rooms according to the manufacturer's recommendations and regulatory guidelines and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security .
235062 03/20/2025
Grandvue Medical Care Facility 1728 South Peninsula Road East Jordan, MI 49727
to be ready for pick-up by 4:00 PM Monday through Friday so evening lab draws were an impossibility.
the testing. RN N asserted, I don't know how that's feasible! I've had heated [NAME] about this lab.
The Assistant Director of Nursing (ADON) was interviewed on [DATE] 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] 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 .
235062 03/20/2025
Grandvue Medical Care Facility 1728 South Peninsula Road East Jordan, MI 49727
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.
235062 03/20/2025
Grandvue Medical Care Facility 1728 South Peninsula Road East Jordan, MI 49727
accordance with current CDC guidelines and recommendations . A series of vaccinations will be
education regarding the benefits and potential side effects of pneumococcal immunization. b.
The
or refusal .
Review of the EMR demonstrated the laboratory draw was obtained on [DATE].
The laboratory report read Test not performed.
Specimen submitted in expired/outdated collection device.
The laboratory report documented the specimen was obtained on [DATE] but not reported until [DATE].
R25 was transferred to the hospital Emergency Department on [DATE] and the hospital obtained an INR.
The EMR of 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] was reported to the facility on [DATE]. A laboratory report containing critical results was obtained on [DATE] and reported to the facility [DATE].
The results of an INR collected on [DATE] was reported to the facility on [DATE]. A laboratory result collected on [DATE] was reported on [DATE].
235062
Form Approved OMB
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
F-F883 Grandvue
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 (R36)
A nurse progress notes in the EMR (Electronic Medical Record) on 12/3/24 documented R36 was confused with no verbal response to questioning. 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 R36 transferred to the Emergency Department (ED) for evaluation. R36 was subsequently admitted to the hospital with Pneumonia.
A review of the EMR for R36 revealed an [AGE] year-old resident admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 indicating R36 was cognitively intact on admission.
The MDS documented the pneumococcal vaccinations for R36 were up to date.
A vaccination consent form signed by R36 on 6/5/24 documented 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 R36 was reviewed on 3/20/25 and revealed R36 received the PCV13 vaccination on 5/18/15 and a PPSV23 vaccination on 10/31/07. No further pneumococcal vaccinations were administered to R36, including the PCV20 recommended by the CDC and requested on the consent form signed by R36.
There was no physician's documentation in the Electronic Medical Record (EMR) for R36 indicating the physician addressed the request for administration of PCV20 for R36.
Resident #75 (R75)
R75 was an [AGE] year-old resident admitted to the facility on [DATE]. 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] documented the pneumococcal vaccinations for R75 were up to date.
An immunization report for R75 was reviewed on 3/20/25 and revealed R75 received PCV13 on 10/5/16 and PPSV23 on 6/1/18. No further pneumococcal vaccinations had were administered to R75, including the PCV20 recommended by the CDC and as requested on the consent signed by the resident representative of R75.
235062
Form Approved OMB
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
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.