Inspection Reports for Stonegate Health Campus
2525 Demille Rd, Lapeer, MI 48446, United States, MI, 48446
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
92% worse than Michigan average
Michigan average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
71 residents
Based on a September 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 16, 2025
Visit Reason
The inspection was conducted following a complaint investigation regarding the misappropriation of resident property, specifically missing money reported by Resident #218.
Complaint Details
The complaint investigation was substantiated with findings that Resident #218 had $448 missing from her purse kept in a locked bedside drawer. The facility's investigation included police involvement, staff interviews, and review of admission inventories. The police did not pursue the case further. The facility lacked adequate staff training on resident trust funds and safeguarding valuables.
Findings
The facility failed to prevent the misappropriation of Resident #218's money, resulting in $448 missing from a locked bedside drawer. The investigation included interviews with the resident, staff, family, and local police, revealing lapses in securing the resident's belongings and incomplete staff education on safeguarding resident valuables.
Deficiencies (1)
Failed to protect Resident #218 from wrongful use of belongings resulting in missing $448.
Report Facts
Missing money amount: 448
Date of incident: Nov 18, 2024
Date of investigation interview: Jan 15, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide L | Nurse Aide | Documented admission inventory and facility guidelines on valuables. |
| Officer M | Police Officer | Conducted investigation and interviewed Resident #218 regarding missing money. |
| Confidential Person J | Interviewed about Resident #218's handling of money and memory status. | |
| Director of Nursing | Director of Nursing | Interviewed about inventory process and staff training related to resident money. |
| Administrator | Administrator | Interviewed multiple times regarding investigation, staff education, and police report. |
Inspection Report
Routine
Deficiencies: 5
Date: Jan 16, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to respiratory care, medication storage and administration, food preferences, infection prevention and control, and other resident care standards.
Findings
The facility was found deficient in several areas including improper oxygen administration and storage, expired medication supplies not discarded properly, failure to follow food preferences for a resident, lapses in infection prevention and control practices including hand hygiene and PPE use, and unsafe medication administration practices.
Deficiencies (5)
Failed to ensure safe and sanitary storage of respiratory equipment and oxygen provided as ordered for residents #3, #272, and #273.
Failed to ensure expired supplies were discarded and medications to be discarded were stored properly, resulting in expired supplies and medications being available for use.
Failed to ensure drugs and biologicals were labeled and stored in locked compartments, and proper medication administration and disposal procedures were followed.
Failed to ensure food preferences were followed for Resident #271, resulting in unhappiness and decreased breakfast consumption.
Failed to provide and implement an infection prevention and control program, including hand hygiene during medication administration, proper PPE use, and safe storage of resident care items.
Report Facts
Expired sterile gloves boxes: 4
Expired vacutainers: 12
Oxygen liters ordered: 4
Oxygen liters observed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse H | Nurse | Observed improper medication administration and handling, including placing medications in a cup and handling with bare hands. |
| Director of Nursing | Director of Nursing/DON | Interviewed regarding oxygen order discrepancy for Resident #3 and medication administration practices. |
| Nurse Aide G | Nurse Aide | Observed not wearing PPE properly while caring for Resident #38 in Transmission-Based Precautions. |
| Corporate Nurse K | Corporate Nurse | Reviewed medication administration observation with Nurse H and planned re-education. |
| Infection Prevention and Control Nurse F | IPC Nurse | Confirmed Resident #38 was in Transmission-Based Precautions and reviewed cluttered sink in Resident #22's room. |
| Licensed Practical Nurse B | LPN | Verified expired medication findings in 300 Hall medication storage room. |
| Registered Nurse C | RN | Verified expired medication findings in 100 Hall medication storage room. |
| Director of Sales A | Director of Sales | Verified expired medication findings in 100 Hall medication storage room. |
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 1
Date: Sep 19, 2024
Visit Reason
The inspection was conducted based on complaints regarding residents not being treated with dignity and respect, including issues with call lights not being answered timely and concerns about staff behavior and facility conditions.
Complaint Details
The investigation pertained to Intake Numbers MI00142107 and MI00144987 involving two confidential residents who reported issues including call lights being turned off without completing nursing tasks, lack of basic supplies, insufficient CNA staffing, poor food quality, and disrespectful staff behavior. The complaints were substantiated by interviews and observations.
Findings
The facility failed to ensure residents were treated respectfully and with dignity, as evidenced by verbal reports from two residents and their family members about call lights being turned off prematurely, inadequate staffing, poor food quality, and dismissive staff behavior. Policies on call light response and resident rights were reviewed.
Deficiencies (1)
Failure to honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Report Facts
Facility census: 71
Residents affected: 2
Inspection Report
Renewal
Census: 20
Capacity: 39
Deficiencies: 0
Date: Aug 16, 2024
Visit Reason
The inspection was conducted as a renewal inspection to determine compliance with applicable licensing statutes and rules for Stonegate Health Campus.
Findings
The facility was found to be in substantial compliance with the public health code and administrative rules regulating home for the aged facilities. Renewal of the license is recommended.
Report Facts
Number of staff interviewed and/or observed: 8
Number of residents interviewed and/or observed: 20
Capacity: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Flood | Administrator/Authorized Representative | Named as the facility administrator and authorized representative |
| Aaron Clum | Licensing Consultant | Signed the report and recommended license renewal |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Jan 9, 2024
Visit Reason
The inspection was conducted based on complaints and allegations related to care planning, activities of daily living assistance, pressure ulcer care, accident hazards, supervision, and medication management.
Complaint Details
The complaint investigation included allegations of failure to create baseline care plans, revise care plans, provide ADL assistance, prevent pressure ulcers, prevent unauthorized exits, follow transfer care plans, and manage medications properly. The investigation found substantiated deficiencies in all these areas with actual and potential harm to residents.
Findings
The facility failed to ensure baseline care plans were created upon admission for edema, care plans were revised to reflect current healthcare orders, appropriate assistance with activities of daily living was provided, pressure ulcer care and prevention were adequately implemented, accident hazards were minimized with adequate supervision, and medication regimens were free from unnecessary drugs. These failures resulted in potential or actual harm including unmet care needs, injury, pain, and increased risk of pressure ulcers and unsafe exits.
Deficiencies (8)
Failed to create a baseline care plan for edema upon admission for Resident #272, resulting in lack of monitoring and interventions.
Failed to revise care plans to accurately reflect current healthcare providers' orders for Resident #57, leading to inappropriate care and injury risk.
Failed to provide timely and appropriate assistance with activities of daily living for five residents, resulting in unmet care needs and injury risk.
Failed to implement and operationalize procedures for pressure ulcer assessment, documentation, and management for Resident #272, resulting in development of unstageable and stage two pressure ulcers and actual harm.
Failed to prevent unauthorized exit of Resident #222 and failed to complete appropriate elopement risk assessments and investigations, resulting in actual harm.
Failed to follow care-planned transfer status for Resident #1, resulting in falls, fracture, surgery, and pain.
Failed to follow standards of practice with removal of sling underneath Resident #5, resulting in fracture, pain, and decreased mobility.
Failed to ensure a non-viable TSH lab draw was followed up and Levothyroxine medication was given with Calcium simultaneously for Resident #14, increasing risk of decreased absorption and hypothyroidism symptoms.
Report Facts
Deficiencies cited: 8
Braden Scale Score: 14
Braden Scale Score: 11
TSH lab result: 7
Wound measurements: 3.5
Wound measurements: 2
Wound measurements: 6
Wound measurements: 5.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN C | MDS Registered Nurse | Interviewed regarding failure to create baseline care plan for edema and care plan revisions |
| Director of Nursing | DON | Interviewed regarding care plan deficiencies, pressure ulcer care, and elopement incident |
| RN F | Clinical Registered Nurse | Interviewed regarding Resident #272 ADL care concerns and Resident #222 elopement investigation |
| CNA G | Certified Nursing Assistant | Interviewed regarding Resident #272 ADL care and pressure ulcer observations |
| Wound Care RN D | Wound Care Registered Nurse | Interviewed regarding pressure ulcer assessments and documentation for Resident #272 |
| PTA V | Physical Therapy Assistant | Interviewed regarding Resident #57's knee brace application and staff training |
| Nurse S | Nurse | Interviewed regarding Resident #56 shaving policy |
| CNA T | Certified Nursing Assistant | Interviewed regarding Resident #56 shaving care |
| CNA L | Certified Nursing Assistant | Interviewed regarding Resident #56 shaving and showering activities |
| NP CC | Nurse Practitioner | Interviewed regarding Resident #14's TSH lab follow-up and medication management |
| CRCA L | Certified Resident Care Associate | Interviewed regarding Resident #1 fall and transfer assistance |
| Administrator | Facility Administrator | Interviewed regarding Resident #222 unauthorized exit and investigation |
Inspection Report
Complaint Investigation
Deficiencies: 12
Date: Jan 9, 2024
Visit Reason
The inspection was conducted based on complaints and observations related to resident care, including failure to provide timely assistance, accessible call lights, provision of residents' rights, baseline care plans, care plan revisions, activities of daily living assistance, pressure ulcer care, accident prevention, catheter care, medication security, respiratory care, and infection control.
Complaint Details
The complaint investigation included issues related to resident care, safety, medication management, infection control, and regulatory compliance as detailed in the findings.
Findings
The facility failed to provide timely assistance and accessible call lights for residents, delayed provision of residents' rights, lacked baseline care plans for edema, did not revise care plans accurately, failed to provide appropriate ADL care, did not implement proper pressure ulcer care, failed to prevent unauthorized resident exit, did not follow transfer status and sling removal standards, improperly managed indwelling urinary catheter care, failed to provide fortified shakes per physician orders, did not ensure cleaning of CPAP machines, failed to secure medications properly, and lacked a comprehensive infection control program including PPE use and infection surveillance.
Deficiencies (12)
Failure to provide timely assistance and accessible call lights for residents resulting in lack of timely care and resident distress.
Failure to ensure provision of residents' rights prior to or upon admission resulting in delay of communication and receipt of rights.
Failure to create and implement a baseline care plan for edema upon admission resulting in lack of monitoring and interventions.
Failure to revise care plans accurately reflecting current healthcare providers' orders resulting in risk of inappropriate care.
Failure to provide appropriate ADL care per residents' needs and care plans resulting in unmet care needs and injury risk.
Failure to implement and operationalize pressure ulcer assessment, documentation, and management resulting in development of unstageable and stage two pressure ulcers.
Failure to ensure nursing home area is free from accident hazards and provide adequate supervision to prevent accidents, including unauthorized resident exit.
Failure to provide appropriate care for residents with indwelling urinary catheters resulting in inappropriate positioning of drainage tubing and bags.
Failure to provide enough food/fluids to maintain resident's health, including failure to provide fortified shakes per physician orders.
Failure to provide safe and appropriate respiratory care, including failure to ensure cleaning of CPAP machine resulting in potential for infection.
Failure to provide pharmaceutical services to meet resident needs, including failure to secure medications and complete narcotic reconciliation.
Failure to provide and implement a comprehensive infection prevention and control program, including surveillance, data collection, PPE use, and infection tracking.
Report Facts
Deficiencies cited: 12
Pressure ulcer size: 3.5
Pressure ulcer size: 2
Pressure ulcer size: 6
Pressure ulcer size: 5.5
TSH lab result: 7
Medication doses: 175
Medication doses: 600
Infections: 22
Nosocomial infections: 8
Community acquired infections: 14
Respiratory infection rate: 1.5
Skin infection rate: 1.5
UTI infection rate: 8.8
Braden Score: 14
Braden Score: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse F | Clinical Registered Nurse | Interviewed regarding call light accessibility and Resident #30's care |
| Director of Nursing | Director of Nursing | Interviewed regarding call light accessibility, care plans, pressure ulcer care, and infection control |
| Nurse E | Nurse | Observed assisting Resident #20 with call light out of reach |
| Physical Therapy Assistant V | Physical Therapy Assistant | Interviewed regarding Resident #57's knee brace application and staff training |
| MDS Registered Nurse C | MDS Registered Nurse | Interviewed regarding care plan revisions and wound documentation |
| Wound Care Registered Nurse D | Wound Care Registered Nurse | Interviewed regarding pressure ulcer assessment and documentation for Resident #272 |
| Certified Nursing Assistant G | Certified Nursing Assistant | Observed and interviewed regarding Resident #272's care and catheter bag positioning |
| Nurse U | Nurse | Observed leaving medication cart unlocked |
| Nurse W | Nurse | Interviewed regarding narcotic reconciliation and Resident #6's meal |
| Kitchen Director BB | Kitchen Director | Interviewed regarding fortified shakes for Resident #4 |
| Infection Control Nurse M | Infection Control Nurse | Interviewed regarding infection control data and surveillance |
| Nurse Practitioner CC | Nurse Practitioner | Interviewed regarding Resident #14's TSH lab and medication |
| Certified Resident Care Associate L | Certified Resident Care Associate | Interviewed regarding Resident #1's fall and transfer status communication |
Inspection Report
Renewal
Deficiencies: 0
Date: Aug 8, 2023
Visit Reason
The document serves to notify that the Home for the Aged license for Stonegate Health Campus has been renewed for a 12-month period effective 08/05/2023.
Findings
The license renewal confirms that the facility's license is valid only at the listed address and is not transferable.
Report Facts
License duration: 12
License effective date: Effective date of license is 08/05/2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Aaron L. Clum | Licensing Staff | Signed the license renewal letter |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Jun 7, 2023
Visit Reason
The inspection was conducted based on complaints and allegations regarding care planning participation, abuse allegations, fall safety, and staffing concerns at Stonegate Health Campus.
Complaint Details
This investigation was complaint-driven, involving allegations of lack of care conferences, abuse allegations by staff towards Resident #6, fall safety concerns, and staffing shortages. The abuse allegations were not substantiated by the facility investigation, which was found to be incomplete and lacking interviews with all involved parties.
Findings
The facility failed to hold regularly scheduled care conferences for several residents, failed to timely report and investigate abuse allegations, failed to provide safe transfer and fall precautions after a resident's fall, and failed to provide sufficient nursing staff to meet resident needs. Additionally, the facility did not maintain accurate daily nurse staffing postings.
Deficiencies (6)
Failed to hold regularly scheduled care conferences for residents and their representatives, resulting in lack of involvement in care planning.
Failed to operationalize abuse policy by not timely reporting abuse allegations and allowing staff to continue care after allegations, resulting in delayed investigation and potential for abuse.
Failed to complete a thorough systemic investigation of abuse allegations by not interviewing all potential witnesses and lacking documentation.
Failed to provide safe transfer after a fall and implement fall precautions upon return to the facility, resulting in potential for further injury and pain.
Failed to provide sufficient nursing staff to meet resident needs, resulting in complaints of unmet care needs, extended call light wait times, and potential worsening of wounds.
Failed to ensure required posting of daily nurse staffing was accurate and updated, resulting in lack of accurate documentation and accessible staffing information.
Report Facts
Residents reviewed for care planning participation: 7
Residents affected by care conference deficiency: 5
Residents reviewed for abuse: 6
Residents reviewed for falls: 3
Residents with staffing complaints: 7
Facility census: 78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse I | Nurse | Involved in abuse allegation investigation and care of Resident #6. |
| Nurse S | Night Shift Nurse Supervisor | Involved in abuse allegation investigation and care of Resident #6. |
| CNA O | Certified Nursing Assistant | Involved in abuse allegation investigation and care of Resident #6. |
| CNA N | Certified Nursing Assistant | Involved in abuse allegation investigation and care of Resident #6. |
| Confidential Person K | Resident Representative/Power of Attorney | Reported abuse allegations and concerns about care for Resident #6. |
| Social Worker C | Social Worker | Interviewed regarding care conferences. |
| Clinical Support Nurse A | Clinical Support Nurse | Interviewed regarding care conferences and abuse allegations. |
| Administrator | Nursing Home Administrator (NHA) | Interviewed regarding care conferences, abuse investigation, staffing, and policies. |
| Staffing Coordinator R | Staffing Coordinator | Interviewed regarding staffing schedules and posting. |
| Confidential Staff U | Confidential Staff | Reported staffing concerns. |
| Confidential Staff V | Confidential Staff | Reported staffing concerns. |
| Confidential Staff W | Confidential Staff | Reported staffing concerns. |
| Nurse Q | Nurse | Assisted in transferring Resident #6 after fall. |
| Confidential Person E | Resident Representative | Reported concerns about Resident #3's care. |
Inspection Report
Routine
Deficiencies: 17
Date: Oct 10, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, abuse prevention, infection control, medication management, and overall facility operations.
Findings
The facility was found deficient in multiple areas including failure to honor residents' rights to menu choices when eating in their rooms, incomplete advance directive care plans, inadequate personal belongings management during room transfers, unsafe and unclean environment, neglect of a resident resulting in pain and verbal abuse, failure to report abuse and injury, incomplete care plans, inadequate assistance with activities of daily living, failure to provide appropriate treatment and monitoring for skin tears and burns, improper medication storage and labeling, failure to maintain infection preventionist role, and lack of staff training and competency evaluations.
Deficiencies (17)
Failed to honor residents' rights and preferences in ordering food items from the menu when eating in their room, limiting choices and causing frustration.
Failed to ensure an updated Advance Directive care plan with accurate code status information for one resident.
Failed to ensure personal belongings were moved with a resident after a room transfer, resulting in delayed access.
Failed to maintain a safe, clean, comfortable and homelike environment, including cluttered sinks, strong urine odors, and unclean resident rooms.
Failed to protect a resident from neglect, resulting in being left in bed with incontinence and complaints of pain and verbal abuse.
Failed to timely report suspected abuse and neglect and failed to investigate and report an injury of unknown origin.
Failed to develop and implement complete care plans that meet all resident needs for two residents, resulting in unmet care needs.
Failed to provide grooming assistance for facial hair for four residents dependent on staff, resulting in unshaven faces and potential loss of dignity.
Failed to provide appropriate treatment and care for skin tears and burns, including lack of physician notification and wound assessment.
Failed to ensure safe practices to prevent a burn from hot coffee and failed to implement fall prevention measures, resulting in actual harm to residents.
Failed to provide appropriate care for urinary catheter, including hand hygiene, catheter care, and notification of refusal for catheter change.
Failed to provide enough food and fluids to maintain a resident's health, including failure to follow care-planned interventions and assess assistance needs timely.
Failed to provide appropriate respiratory care for a resident using BIPAP, resulting in unsanitary storage of equipment.
Failed to ensure nurses and nurse aides received yearly evaluations and competencies, resulting in potential lack of necessary skills.
Failed to ensure nurse aides were trained and competent within required timeframes, resulting in potential inadequate resident care.
Failed to ensure proper medication labeling and storage, including unsecured medications and expired items, resulting in potential medication errors and safety risks.
Failed to fully implement a policy for food brought into the facility, including labeling and temperature monitoring, increasing risk for food borne illness.
Report Facts
Weight: 163
Weight: 169.4
Weight: 173
Weight: 171.8
Weight: 176.6
Weight: 178.2
Weight: 174.4
Temperature: 166.1
Temperature: 65.1
Count: 13
Count: 4
Count: 21
Count: 12
Count: 15
Inspection Report
Original Licensing
Capacity: 39
Deficiencies: 0
Date: Oct 9, 2012
Visit Reason
The inspection was conducted as an original licensing study to determine compliance with applicable licensing statutes and administrative rules for the Stonegate Health Campus facility.
Findings
The facility was found to be in substantial compliance with licensing requirements, with no rule or statutory violations noted. The report recommends issuance of a six-month temporary license with a maximum capacity of 39 beds.
Report Facts
Capacity: 39
Surety bond amount: 10000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Merlo | Administrator | Interviewed during on-site inspection |
| Patricia J. Sjo | Licensing Staff | Author of the licensing study report |
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