Inspection Reports for
Stonegate Health Campus
2525 Demille Rd, Lapeer, MI 48446, United States, MI, 48446
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Inspection Report — Aug 16, 2024
Original Licensing
Date: Aug 16, 2024
Visit Reason
Original license application.
Findings
The facility was found to be in substantial compliance with the public health code and administrative rules regulating home for the aged facilities.
Inspection Report — Oct 9, 2012
Original Licensing
Date: Oct 9, 2012
Visit Reason
Original license application.
Findings
The study determined substantial compliance with applicable licensing statutes and administrative rules. No rule or statutory violations were found.
Report Facts
License length: 6
7 CMS Surveys
Inspection Report — Jan 16, 2025
Complaint Investigation
Date: Jan 16, 2025
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Investigation of a complaint received on 2024-11-18 about misappropriation of resident property.
Complaint Details
Misappropriation of resident property: established.
Findings
One deficiency was found related to failure to prevent misappropriation of resident property resulting in missing money.
Deficiencies (1)
F 0602 Protect each resident from the wrongful use of the resident's belongings or money: the facility failed to prevent misappropriation of Resident #218's money totaling $448.00 while at the facility due to unsecured locked drawer and lack of staff education.
Inspection Report — Jan 16, 2025
Complaint Investigation
Date: Jan 16, 2025
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Investigation of a complaint received on 2025-01-16 about respiratory care, medication storage, food preferences, infection prevention and control.
Complaint Details
Respiratory care oxygen setting and storage: established. Medication storage of expired supplies: established. Food preferences not followed: established. Infection prevention failures including hand hygiene and PPE use: established.
Findings
Five rule violations were established related to oxygen administration and storage, expired medication storage, food preferences, infection prevention and control practices including hand hygiene and PPE use.
Deficiencies (4)
F 0695 Provide safe and appropriate respiratory care for a resident when needed: the facility failed to ensure oxygen supplies were stored in a safe and sanitary manner for Residents #3, #272 and #273, and Resident #3's oxygen was set at 5 liters per minute instead of the ordered 4 liters.
F 0761 Ensure drugs and biologicals used in the facility are labeled and stored properly: expired supplies and medications were found in multiple medication storage rooms, including sterile gloves, wound dressings, blood collection kits, and syringes.
F 0806 Ensure each resident receives food that accommodates allergies, intolerances, and preferences: Resident #271 received a sausage patty despite disliking pork, resulting in unhappiness and decreased breakfast consumption.
F 0880 Provide and implement an infection prevention and control program: failures included improper hand hygiene during medication administration for Residents #40 and #42, improper PPE use for Resident #38 in Transmission-Based Precautions, and unsafe storage of resident care items near the sink in Resident #22's room.
Inspection Report — Sep 19, 2024
Complaint Investigation
Date: Sep 19, 2024
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Investigation of a complaint received on 2024-09-19 about resident dignity, call light response, and staff treatment.
Complaint Details
Resident dignity and respectful treatment: violation established. Call light response issues: violation established.
Findings
The facility failed to ensure residents were treated with dignity and respect, and call lights were not answered timely or were turned off prematurely, resulting in resident distress and potential harm.
Deficiencies (1)
F 0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights: the facility failed to ensure residents were treated in a respectful and dignified manner, call lights were turned off without completing nursing tasks, and residents expressed feelings of lack of dignity and belittlement.
Inspection Report — Jan 9, 2024
Complaint Investigation
Date: Jan 9, 2024
Visit Reason
Investigation of complaints regarding resident care, supervision, and safety concerns.
Findings
The facility failed to implement appropriate pressure ulcer care for Resident #272, failed to prevent an unauthorized exit for Resident #222, and failed to follow care plans and safe transfer practices for Residents #1 and #5, resulting in actual harm to these residents.
Deficiencies (4)
Resident #272 developed two unstageable deep tissue injury pressure ulcers and a stage two pressure ulcer due to lack of accurate and timely assessments, lack of meaningful interventions, and failure to reposition every two hours.
Resident #222 exited the facility unsupervised through the main entrance door and was found sitting in the parking lot, indicating failure to prevent unauthorized exit and inadequate supervision.
Resident #1 sustained a periprosthetic fracture of the distal femur after a fall during transfer when staff failed to use two-person assist as required by the care plan.
Resident #5 had a fracture to the left thigh and decreased mobility due to failure to follow standards of practice with removal of a sling underneath the resident.
Inspection Report — Jan 9, 2024
Renewal
Date: Jan 9, 2024
Visit Reason
Renewal inspection of the adult foster care family home license.
Findings
The facility was found to have multiple deficiencies including failure to provide timely assistance and accessible call lights, failure to provide resident rights upon admission, failure to create baseline care plans, failure to revise care plans, failure to provide appropriate activities of daily living care, failure to provide appropriate pressure ulcer care, failure to prevent unauthorized exit, failure to follow care-planned transfer status, failure to provide appropriate catheter care, failure to follow physician diet orders, failure to ensure cleaning of CPAP machine, failure to safely secure medications, and failure to implement a comprehensive infection control program.
Deficiencies (13)
F 0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights: Resident #20 and Resident #30 call lights were frequently out of reach causing residents to yell for help and feel humiliated.
F 0572 Give residents a notice of rights, rules, services and charges: Resident #272 did not receive resident rights verbally or in writing prior to or upon admission, resulting in lack of knowledge and potential violation of rights.
F 0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted: Resident #272 had edema but no baseline care plan was created upon admission, resulting in lack of monitoring and interventions.
F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: Resident #57's care plans were not revised to accurately reflect current healthcare provider orders, causing conflicting care instructions and risk of inappropriate care.
F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable: Residents #4, #6, #35, #56, and #272 did not consistently receive ADL care per their needs and care plans, including lack of shaving, improper assistance with transfers, and inadequate feeding assistance.
F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing: Resident #272 developed two unstageable pressure ulcers and a stage two pressure ulcer due to lack of timely assessment, documentation, turning and repositioning, and pressure reduction interventions.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: Resident #222 exited the facility unsupervised, with no elopement risk assessment or comprehensive investigation, posing risk of injury and harm.
F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections: Resident #272's indwelling urinary catheter drainage bag and tubing were improperly positioned on the floor without securement, increasing risk of injury and infection.
F 0692 Provide enough food/fluids to maintain a resident's health: Resident #4 did not receive physician-ordered fortified shakes with meals, risking continued weight loss.
F 0695 Provide safe and appropriate respiratory care for a resident when needed: Resident #1's CPAP machine was not cleaned weekly as required, risking infection.
F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist: Medication carts were left unlocked and unattended; narcotic reconciliation sheets contained scribbled out numbers and missing signatures, risking medication diversion.
F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs: Resident #14 had a non-viable TSH lab draw with no follow-up and was given Levothyroxine with Calcium simultaneously, risking decreased absorption and hypothyroidism symptoms.
F 0880 Provide and implement an infection prevention and control program: The facility failed to maintain comprehensive infection surveillance and data analysis, failed to track employee illness, and failed to ensure proper PPE use for isolation precautions, risking spread of infections to all residents.
Inspection Report — Jun 7, 2023
Complaint Investigation
Date: Jun 7, 2023
Visit Reason
Investigation of a complaint received about abuse allegations, fall safety, and staffing concerns at the facility.
Complaint Details
Abuse allegations for Resident #6: delayed reporting and investigation; rough care by CNAs; Resident in pain and transferred to hospital; investigation incomplete with missing interviews and statements. Care conferences: not held quarterly for multiple residents. Fall safety: Resident #6 transferred unsafely after fall with multiple fractures. Staffing: insufficient nursing staff leading to unmet resident needs, long call light wait times, and worsening wounds.
Findings
The facility failed to hold regularly scheduled care conferences for multiple residents, failed to operationalize abuse policies timely, failed to conduct a thorough abuse investigation, failed to provide safe transfer and fall precautions after a fall, and failed to provide sufficient nursing staff to meet resident needs, resulting in multiple deficiencies and resident safety concerns.
Deficiencies (6)
F 0553 Allow resident to participate in the development and implementation of his or her person-centered plan of care: the facility failed to hold regularly scheduled care conferences for five residents, resulting in residents and representatives being uninformed and not involved in their plan of care.
F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft: the facility failed to operationalize the abuse policy by not reporting abuse allegations timely and failed to prevent staff from continuing care after abuse allegations for Resident #6, resulting in delayed investigation and potential for abuse.
F 0610 Respond appropriately to all alleged violations: the facility failed to complete a thorough systemic investigation of abuse allegations for Resident #6 by not interviewing all involved persons including the complainant, staff, resident, and EMS personnel, resulting in an incomplete investigation.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to provide a safe transfer after a fall and implement fall precautions upon return to the facility for Resident #6, including lifting the resident under the arms without a gait belt or mechanical lift despite multiple fractures.
F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift: the facility failed to provide sufficient nursing staff for 78 residents, resulting in complaints of short staffing, extended call light wait times, unmet care needs, incontinent episodes, and delayed care.
F 0732 Post nurse staffing information every day: the facility failed to ensure that required posting of daily nurse staffing was accurate and updated, resulting in inaccurate documentation of daily staffing and lack of accessible staffing information.
Inspection Report — Oct 10, 2022
Monitoring
Date: Oct 10, 2022
Visit Reason
Interim inspection to determine compliance.
Findings
Resident #14 sustained a second degree burn from hot coffee; Resident #218 fell during transfer resulting in facial abrasions and a hand fracture; multiple medication storage and labeling deficiencies were observed; Resident #40 had catheter care issues with refusal of catheter change and poor hygiene; Resident #42 experienced weight loss and inadequate meal assistance; Resident #64's BIPAP equipment was stored unsanitarily; nurse aides lacked required annual evaluations and training; infection preventionist role was vacant since May 2022.
Deficiencies (13)
Resident #14 sustained a second degree burn on the right thigh from hot coffee spilled on him; the burn was not reported until the next day and no additional preventive measures were implemented to protect other residents.
Resident #218 fell during transfer, resulting in facial abrasions and a mildly displaced intra-articular fracture of the right hand; care plan and transfer orders were inconsistent and gait belt was not used during transfer.
Medication storage deficiencies included unlocked medication carts with hypodermic syringes accessible to residents, expired medications and supplies in medication rooms, and unsecured medications in refrigerators.
Resident #40 had a Foley catheter with large sediment buildup and foul odor; catheter care was inadequate, resident refused catheter change, and staff touched catheter tubing with dirty gloves.
Resident #42 experienced ongoing weight loss and inadequate meal assistance; meals were served cold and not cut up, and resident took hours to eat without staff assistance.
Resident #64's BIPAP mask was stored in a soiled condition, lying face down on the bed or nightstand, increasing risk of infection.
Nurses R and Y and Certified Nursing Assistant C lacked required annual evaluations; CNA C also lacked the required 12 hours of annual training.
Nurse Aide N worked in the long-term care unit without being certified as a nursing assistant, contrary to federal requirements.
Certified Nursing Assistant C did not complete the required 12 hours of annual nurse aide training, having only 7.5 hours documented.
Resident #29 did not have a restorative therapy plan or range of motion exercises on the care plan despite contractures and limited mobility; documentation of ROM was not available.
Resident #66 received ongoing PRN Ativan for anxiety without documented physician oversight or follow-up assessment.
Facility failed to designate a qualified infection preventionist since May 2022; the Director of Nursing was serving as full-time DON and infection preventionist without additional support.
Facility failed to fully implement policy for food brought into the facility by visitors; food items in common area refrigerators were unlabeled, expired, and temperature logs were incomplete.
Report Facts
Coffee temperature: 166.1
Burn size: 2 cm x 4.5 cm
Skin tear size: 1.3 cm x 0.7 cm
Weight: 163
Weight: 169.4
Weight: 173
Weight: 171.8
Weight: 176.6
Weight: 178.2
Weight: 174.4
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