Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Grandvue Medical Care Facility during CMS and state inspections, most recent first.
A resident with dementia, aphasia, urinary incontinence, and severely impaired decision-making was being assisted with a brief change by a CNA, with a second CNA called in to help due to the resident’s history of combative behavior. During the interaction, the resident became agitated, stood up, removed his brief, and made physical contact with both CNAs before eventually returning to bed and making a rude remark. One CNA then responded by calling the resident a derogatory expletive while still in the room, an exchange overheard by a social worker who entered and found one CNA present and the other leaving. Subsequent interviews with both CNAs and the social worker confirmed that the CNA directed the expletive at the resident, constituting verbal abuse under the facility’s abuse policy and resulting in psychosocial harm and mental anguish based on a reasonable person standard.
A resident with Alzheimer's disease experienced significant, unaddressed weight loss after a CNA repeatedly falsified weight documentation over several weeks. Despite concerns raised by the resident's power of attorney about the resident's declining condition, facility staff assured them there was no weight loss, relying on inaccurate records. The deficiency was confirmed through interviews, record review, and video evidence, revealing that weights were not properly obtained or documented, resulting in neglect.
A resident with severe cognitive impairment and a history of falls was found sitting on the floor in another room with visible injuries, including skin tears and a bruised heel. Multiple staff assessed and treated the injuries, but did not immediately document the incident or injuries in the EMR, and required risk management documentation was not completed. Staff interviews revealed confusion about care plan instructions and reporting protocols, and facility policy confirmed that documentation should have occurred for unwitnessed falls and skin injuries.
Two residents were rehospitalized due to the facility's failure to follow physician orders. One resident received warfarin earlier than prescribed, resulting in a supratherapeutic INR, while another did not receive prescribed antibiotics for a UTI, leading to urosepsis. Communication breakdowns and procedural lapses contributed to these deficiencies.
The facility failed to ensure the QAPI committee met quarterly with required members, as the Medical Director or designee did not attend a meeting in one quarter, and no meetings were held in August or September. The DON was unaware of the absence and did not provide proof of attendance.
The facility failed to provide written notification to residents and/or their representatives regarding the reasons for hospital transfers. This deficiency was identified for four residents, including one with dementia and Parkinson's disease and another with a traumatic brain injury. Despite having a procedure and form for issuing notifications, the facility did not complete the necessary documentation, and the reason for this lapse was not explained.
The facility failed to properly label and dispose of medications, with expired and incorrectly dated medications found in multiple medication carts and a storage room. Insulin pens lacked proper expiration dates, and a discontinued controlled substance was not destroyed promptly. The DON acknowledged the need for staff re-education on medication management processes.
A resident with severe cognitive impairment and a history of cerebrovascular accident was inaccurately documented in the MDS assessment as requiring a wander/elopement alarm. Despite staff reports indicating no attempts to leave the locked unit in over a year, the facility failed to conduct the necessary quarterly risk assessments. The oversight was acknowledged by the DON, and the facility did not provide a policy on alarm assessments upon exit.
A facility failed to update the care plan for a resident with severe cognitive impairment and pressure injuries. The care plan lacked specific instructions on repositioning frequency, despite the resident's dependence on staff for mobility and the presence of a Kennedy ulcer. Staff relied on a bedside care plan report, which also omitted necessary details, leading to potential unmet care needs.
A resident with a prosthetic heart valve on warfarin therapy experienced delays in INR testing due to the facility's contracted laboratory service's limited availability. The resident required daily INR checks, but the lab was closed on weekends and had early weekday cutoffs, leading to delayed results and a test not performed due to an expired collection device. Staff expressed concerns about the lab's service, impacting the resident's care.
The facility failed to administer the recommended pneumococcal vaccinations or document reasons for withholding them for three residents. Despite consent forms indicating their wish to receive the PCV20 vaccine, none of the residents received it, and there was no physician documentation addressing the vaccine consideration. The Infection Preventionist confirmed the lack of vaccine administration and documentation, contrary to the facility's policy.
Verbal Abuse of Cognitively Impaired Resident by CNA During Personal Care
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a CNA during in-room care. The resident was an elderly male with dementia, aphasia, overactive bladder, urinary incontinence, and a need for assistance with personal care, and his MDS showed severely impaired cognitive skills for daily decision-making. On the morning in question, a social worker (SW A) was entering her office when she overheard a staff member down the hall say, "You're being a complete [expletive]." SW A then entered the resident’s room and found one CNA (CNA B) bagging trash and observed another CNA (CNA/Perpetrator E) quickly leaving the room. When SW A informed CNA B of what she had overheard, CNA B indicated that CNA/Perpetrator E had made the statement toward the resident. In a later interview, CNA B reported that she had been assisting the resident with a brief change and, although the resident was known to be combative at times, he was initially in a good mood and cooperative. When CNA B could not complete fastening the brief alone, she called CNA/Perpetrator E for help and believed the loud tone and speed of CNA/Perpetrator E’s work may have upset the resident. The resident then stood up, removed his brief, and moved toward the door; CNA B attempted to redirect him by closing the curtain, during which he nudged her and laid hands on CNA/Perpetrator E. CNA B stated the resident eventually lay back down and made a rude remark under his breath, prompting CNA/Perpetrator E to say, "You're being a complete [expletive]." In a separate interview, CNA/Perpetrator E confirmed that after the resident had twisted her wrist and arm, attempted to push CNA B, and later kicked her in the back as she turned to leave, she called him an "[expletive]" while still in the room and acknowledged he probably heard her. The facility’s abuse policy defines verbal abuse as willful use of disparaging or derogatory language within a resident’s hearing, regardless of their ability to comprehend, and the incident was substantiated as mental abuse causing psychosocial harm and mental anguish based on a reasonable person standard.
Failure to Accurately Monitor and Record Resident Weights Resulting in Unaddressed Significant Weight Loss
Penalty
Summary
The facility failed to monitor and accurately record the weights of a resident with Alzheimer's disease, resulting in a significant, unaddressed weight loss. The resident was admitted at a weight of approximately 205 pounds and was noted to have severe cognitive impairment. Over a period of several weeks, staff, specifically a CNA, falsified weight documentation, recording inaccurate weights for at least eight consecutive weekly entries. This led to the facility not recognizing or intervening in the resident's substantial weight loss, which was eventually discovered to be 25.5 pounds. The resident's designated power of attorney repeatedly raised concerns about the resident's declining condition and appearance, but the facility assured them that no weight loss had occurred, based on the falsified records. Interviews and record reviews confirmed that the CNA responsible for obtaining and documenting weights did not consistently perform the task and instead entered false data. The CNA's skills checklist for measuring and recording weight was left incomplete, and the DON confirmed through video review that weights were not being properly obtained. The resident was observed to appear thin and expressed a lack of appetite. The facility's own policy defines neglect as the failure to provide necessary goods and services to avoid harm, and the investigation concluded that both abuse and neglect had occurred in this case.
Failure to Document Unwitnessed Fall and Injuries in Medical Record
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident following an unwitnessed fall. The resident, who had a history of dementia, repeated falls, bone density disorder, and severe cognitive impairment, was found sitting on the floor in another resident's room. Multiple staff members, including CNAs and LPNs, observed and assessed the resident, noting visible injuries such as skin tears on the right forearm and bruising on the left heel. Despite these findings, there was no immediate documentation of the incident or injuries in the resident's electronic medical record (EMR) by the staff who first responded. The care plan for the resident indicated that sitting on the floor was only considered intentional and not a fall if it was witnessed. In this case, the event was unwitnessed, and staff were uncertain whether to classify it as a fall. As a result, required risk management documentation and event reporting were not completed at the time of the incident. The lack of documentation persisted even after subsequent staff discovered and treated the injuries, with some staff expressing confusion about the care plan and reporting requirements. Interviews with staff and review of facility policy confirmed that risk management documentation should have been completed for any unwitnessed fall or skin injury, including skin tears. The omission of this documentation was acknowledged by several staff members, including the DON, who stated that the expected protocol was not followed. The deficiency was identified through observation, interviews, and record review, revealing a failure to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards.
Medication Management Failures Lead to Rehospitalization
Penalty
Summary
The facility failed to follow physician orders for two residents, leading to their rehospitalization. Resident #25, who had a history of gastrointestinal bleeding and was on warfarin therapy, was readmitted to the facility with specific instructions to resume warfarin on a later date. However, the facility administered the medication earlier than prescribed, resulting in a supratherapeutic INR and subsequent rehospitalization. The facility's inability to monitor INR levels effectively due to laboratory service limitations further exacerbated the situation. Resident #15 was discharged from the hospital with a prescription for amoxicillin to treat a urinary tract infection and sepsis. However, the facility failed to administer the antibiotic as it was not reflected in the Medication Administration Record. The resident's condition worsened, leading to a return to the hospital with urosepsis. The facility's on-call provider was unable to access the resident's chart or receive the hospital discharge instructions, contributing to the failure to administer the prescribed medication. Interviews with facility staff revealed communication breakdowns and procedural lapses. The Director of Nursing and Medical Director were unaware of the medication errors until after the residents' conditions had deteriorated. The facility's practice of having providers enter their own orders into the electronic medical records contributed to the oversight, as the necessary orders were not entered or followed. These deficiencies highlight significant lapses in medication management and communication within the facility.
QAPI Committee Meeting Deficiency
Penalty
Summary
The facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) committee met at least once per quarter with the required committee members, which could potentially lead to quality-of-care concerns for all 93 residents. A review of the facility's QAPI sign-in sheets revealed that meetings were held on several dates, but the Medical Director or designee did not attend the meeting on 7/17/24. Additionally, there were no QAPI meetings held in August or September 2024, and the Medical Director or designee did not attend any meetings during the quarter of July, August, and September. During an interview, the Director of Nursing (DON) was unaware of the Medical Director's absence and failed to provide proof of attendance by the survey exit date.
Failure to Provide Written Notification for Resident Transfers
Penalty
Summary
The facility failed to provide written notification to residents and/or their representatives regarding the reasons for transfers to the hospital. This deficiency was identified for four residents who were transferred out of the facility. For Resident #87, the electronic medical record indicated a transfer to an acute care hospital due to swelling in the left lower extremity and thigh, but the Notification of Transfer and Bed Hold Authorization document did not include the reason for the transfer. Similarly, Resident #34 was sent to the hospital for possible sepsis, but the corresponding notification document lacked the reason for the transfer. Resident #25 was transferred to the hospital multiple times, yet the facility's documentation did not specify the reasons for these transfers. Resident #15 also experienced several hospital transfers, with no documented reasons provided in the notification forms. Interviews with the Assistant Director of Nursing and the Director of Nursing revealed that the facility had a procedure for issuing written notifications of transfer, but the forms were not completed for the residents in question. The facility had a form titled Notice of Resident Transfer or Discharge, which included the necessary requirements, but it was not utilized, and the reason for discontinuing its use was not explained.
Medication Labeling and Disposal Deficiencies
Penalty
Summary
The facility failed to properly label medications and dispose of expired or discontinued medications, as observed in three out of four medication carts and one out of two medication rooms. On March 18, 2025, an insulin pen with an expiration date of March 9, 2025, was found in the Valleyvue B medication cart, and a registered nurse confirmed it should not have been there. Additionally, the Lakevue B medication cart contained expired epinephrine auto-injector pens and an insulin pen without an expiration date. A registered nurse confirmed the epinephrine was expired and acknowledged the requirement for insulin pens to have expiration dates. Further observations revealed that the Lakevue A medication cart contained a haloperidol liquid without an expiration date and an insulin lispro pen with an incorrect expiration date. The cart also had two other insulin pens with incorrect dates. A registered nurse admitted the dates were incorrect. Additionally, a discontinued controlled substance, Lorazepam, was found in the Valleyvue B narcotic book, despite a physician's order to discontinue it on February 7, 2025. The nurse acknowledged that discontinued medications should be destroyed as soon as possible. In the medication storage room on Lakevue, an expired bottle of geri-tussin was found. The Director of Nursing was informed of these findings and confirmed that expired medications should be discarded and discontinued narcotics destroyed promptly. The facility's policies on medication disposal, labeling, and storage were reviewed, indicating that medications should be labeled with open and expiration dates, and expired or discontinued medications should be removed from active supply areas.
Inaccurate MDS Assessment for Resident with Alarm
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment documentation for a resident, identified as Resident #23, who was admitted with diagnoses including cerebrovascular accident, hemiplegia, and dementia. The MDS assessment indicated the use of a wander/elopement alarm daily, despite multiple staff interviews revealing that the resident had not attempted to leave the locked unit in over a year. The last risk assessment for the alarm was completed on 8/9/24, and the resident had not been assessed quarterly as required. Interviews with various staff members, including LPNs, CNAs, and the Director of Nursing, confirmed that the resident's condition had changed, and the use of the alarm was no longer necessary. The facility's policy on elopement and wandering residents emphasized the need for systematic monitoring and assessment, which was not adhered to in this case. The Director of Nursing acknowledged the oversight in not conducting the required quarterly assessments, and the facility failed to provide a policy regarding the assessment or use of alarms upon exit.
Failure to Update Care Plan for Resident with Pressure Injuries
Penalty
Summary
The facility failed to update the person-centered care plan for a resident with severe cognitive impairment and dependence on staff for all transfers and bed mobility. The resident, who was admitted with diagnoses including Parkinson's Disease and dementia, was observed with pressure injuries that were not adequately addressed in the care plan. The care plan lacked specific instructions on repositioning frequency, despite the resident's inability to reposition independently and the presence of a Kennedy ulcer noted in a provider's assessment. During observations and interviews, it was revealed that the care staff relied on a bedside care plan report, which also did not include necessary details on repositioning frequency or weight offloading for the resident's wounds. The Nursing Care Coordinator confirmed that the care plan was not updated to reflect the resident's current condition and needs, including the presence of the Kennedy ulcer and the requirement for repositioning every two hours. This oversight resulted in the potential for unmet care needs for the resident.
Failure to Provide Timely Laboratory Services for Anticoagulation Monitoring
Penalty
Summary
The facility failed to provide timely and adequate laboratory services for a resident with a prosthetic heart valve who was prescribed warfarin, an anticoagulant requiring regular monitoring through INR tests. The resident was transferred to the hospital multiple times due to supratherapeutic INR levels, indicating excessive blood thinning. Upon returning from a hospital stay, the discharge instructions specified daily INR checks, but the facility was unable to comply due to limited laboratory service availability on weekends and evenings. This resulted in delayed INR testing and reporting, with one instance where a specimen was submitted in an expired collection device, leading to a test not being performed. Interviews with facility staff, including the Clinical Care Coordinator and the Assistant Director of Nursing, revealed ongoing challenges with the contracted laboratory service provider. The laboratory was not open on weekends, and specimens had to be ready for pick-up by 4:00 PM on weekdays, with testing conducted out of state, causing further delays in receiving results. Despite management being aware of these issues, the facility continued to experience significant delays in obtaining critical laboratory results, impacting the care and safety of the resident.
Failure to Administer and Document Pneumococcal Vaccinations
Penalty
Summary
The facility failed to administer the recommended pneumococcal vaccinations or document the clinical reasons for withholding them for three residents. Resident #36, who was cognitively intact upon admission, had signed a consent form to receive the PCV20 vaccine as per CDC guidelines. However, the resident did not receive the PCV20 vaccine, and there was no documentation from the physician addressing this request. Resident #36 was later transferred to the emergency department with pneumonia. Similarly, Resident #75 and Resident #15, both of whom had consented to receive the PCV20 vaccine, did not receive it, and there was no physician documentation in their EMRs regarding the consideration of the vaccine. The Infection Preventionist confirmed that the residents did not receive the PCV20 vaccine as per their consent forms and that there was no documentation of the vaccine being considered for administration. The facility's policy requires offering pneumococcal vaccinations in accordance with CDC guidelines and documenting the provision of education and the administration or refusal of the vaccine. However, the facility did not adhere to this policy, as evidenced by the lack of documentation and administration of the PCV20 vaccine for the residents in question.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Boulder Park Terrace | 10.9 mi | ★★★★★ | 12 | 0 |
| The Villa At The Bay | 14.5 mi | ★★★★★ | 3 | 0 |
| Meadow Brook Medical Care Facility | 18.4 mi | ★★★★★ | 9 | 0 |
| Bay Bluffs-emmet County Medical Care Facility | 18.8 mi | ★★★★★ | 1 | 0 |
| Medilodge Of Gaylord | 24.6 mi | ★★★★★ | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.