Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Stonegate Health Campus during CMS and state inspections, most recent first.
Food contact surfaces and equipment were observed soiled in multiple areas, including a meat slicer, can opener, mixer, juice machine nozzles, and coffee machine nozzles, with dust and residue noted during kitchen and dining area observations. During meal service, pasta salad was held at 49 F and 52 F, an employee used the same glove after handling raw fish to plate fries, and fried shrimp on the steam table was measured at 127 F, 124 F, and then 114 F, below the facility’s hot-holding standard.
Late completion of quarterly MDS assessments affected six of seven residents reviewed. The MDS Coordinator confirmed quarterly assessments must be completed within 14 days of the ARD and acknowledged a late assessment, while Corporate MDS Support said the unfinished portions were the social services sections and staffing had been limited due to having only one social worker. The NHA also stated the facility had identified the issue and had disciplined the MDS Coordinator for not completing the assessments on time.
Respiratory equipment was not handled according to facility procedure for several residents with COPD and other chronic conditions. Oxygen tubing and humidification canisters were observed without initiation dates for multiple residents, and one resident's nebulizer chamber and mouthpiece were stored on a chair with personal items instead of in clean storage. The facility's SOP required monthly tubing changes, dating of equipment, and proper cleaning and storage of nebulizer supplies.
Missing Physician Code Status Order: A resident with CKD, CHF, heart disease, and dialysis dependence had no physician order for code status in the EMR. The SW said nurses enter code status orders, while the DON said the admission nurse enters the signed DNR or full code order and that a resident is full code by default until the physician signs a DNR. The DON stated the order was missed after the resident returned from the hospital and orders were discontinued.
A resident with diabetes, stroke history, urinary retention, hydronephrosis, and other diagnoses had an MDS showing an indwelling catheter and frequent bowel incontinence, but the care plan did not address the Foley catheter, diarrhea, constipation, or bowel/bladder incontinence. The resident reported frequent diarrhea and discomfort from a buttocks wound, while charting showed catheter malfunction, no urine output, constipation complaints, and use of bowel meds and Imodium.
Failure to provide timely vision services for a resident with cataracts, DM, and hemiplegia/hemiparesis. The resident said her current glasses belonged to her deceased husband, hurt her eyes, and were not comfortable, and she reported asking the facility for vision services without being seen. Records showed she had consented to ancillary services, the SW said residents can be signed up when needs are identified, and the NHA stated the resident should have been signed up when she indicated she wanted services.
Infection prevention and control standards were not followed during wound care for a resident on EBP and in a medication room. A nurse performed coccyx wound care without PPE, used the same gloves throughout the procedure, placed supplies on a cluttered bed tray, and handled the resident’s blankets, call light, and bed remote with soiled gloves. The resident had a new sore coccyx area with MASD, and staff confirmed wound care is a high-contact activity requiring gown and gloves. The 300-hall med room also had applesauce boxes, IV antibiotic supplies, and other items stacked around the sink and under the soap dispenser, leaving no clear space for hand hygiene or med prep, and shared EBP rooms were not initially labeled to identify the resident in bed A or bed B.
The facility failed to discard expired supplies and improperly handled medications. Expired items like sterile gloves and blood collection sets were found in storage rooms. A nurse improperly stored and handled medications, mixing them in a cup and using bare hands to sort them. These practices were not aligned with facility policies.
A resident with full cognitive abilities reported $448 missing from her locked bedside drawer. The facility's investigation revealed that the key was sometimes left unsecured, and the resident was not informed about the Trust Fund option for safekeeping. The facility's admission packet and policy lacked clear guidelines for preventing misappropriation, and staff did not receive adequate training on safeguarding resident belongings.
The facility failed to ensure safe storage of respiratory equipment for three residents and did not provide oxygen as ordered for a resident. One resident's oxygen was set higher than prescribed, and two residents had nasal cannulas improperly stored. The facility's policy on oxygen administration was not adequately followed, leading to potential exposure to infectious organisms.
A resident's food preferences were not followed, leading to dissatisfaction and reduced breakfast consumption. Despite the facility's protocol to ensure meal preferences are adhered to, a resident received a breakfast tray with pork, which they dislike. The resident had communicated this preference daily, and the meal ticket confirmed their dislike for pork, highlighting a lapse in the facility's dining services.
The facility failed to follow Infection Prevention and Control standards, including improper hand hygiene during medication administration, inadequate PPE use for a resident in Transmission-Based Precautions, and improper storage of care items near a sink, risking contamination and infection spread.
Two residents reported feeling disrespected and undignified due to staff actions, including being told to relieve themselves in briefs, inadequate absorbent pads, and unaddressed call lights. The facility's policies on call light response and resident rights were not followed, leading to residents' feelings of belittlement and discontentment.
Food Contact Surfaces Not Clean and Foods Held at Improper Temperatures
Penalty
Summary
The facility failed to maintain best practices in the food service area during observation, interview, and record review. In the kitchen dry storage room, the meat slicer was visibly soiled with crumbs on its surface, metal lids stored on a rack near the handwashing sink had dust accumulation, the can opener was visibly soiled, and the mixer had black and yellow residue. In the dining area near the kitchen, built-up residue was observed on the surface near the nozzles of the juice machine, and in the cafe kitchenette, accumulated residue was observed on the nozzles of the Folgers coffee machine. The Director of Food Services stated the meat slicer is used about twice a year and cleaned before use, the can opener is cleaned every night, the mixer is cleaned every time it is used, and the juice machine and coffee machine nozzles are cleaned on a rotation. During lunch observation, macaroni pasta salad sitting on ice on the food prep line was temped at 49 F, and mechanical pasta salad in a tub without ice on the food prep line was temped at 52 F. The Director of Food Services stated she was not sure what temperature the pasta salad should be cold holding. Later, an employee was observed battering raw fish with one gloved hand, removing the soiled glove with the other gloved hand, and then using the same gloved hand to put fries onto a plate. On the following day, fried shrimp on the steam table was temped at 127 F and 124 F, then retested at 114 F by the Director of Food Services, who stated hot holding is usually around 160 F. The facility's policy stated cold foods should be 40 degrees or less at the time of service and hot food in the steam table should be at least 135 degrees or higher.
Late Completion of Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure MDS assessments were completed timely for six of seven residents reviewed. Record review showed that quarterly MDS assessments for residents with diagnoses including chronic kidney disease, chronic respiratory failure, dependence on renal dialysis, diabetes mellitus, coronary artery disease, hypertension, traumatic brain dysfunction, stroke, hemiplegia, anxiety, depression, chronic kidney disease, anemia, epilepsy, atrial fibrillation, hypothyroidism, acute kidney failure, repeated falls, and cognitive communication deficit were opened on various dates in January 2026 and closed on 01/26/26. Several of the assessments were completed late, including assessments for residents that were 6, 7, 10, and 21 days past the required completion timeframe. During interview, the MDS Coordinator stated quarterly assessments are to be completed within 14 days of the ARD and acknowledged that one reviewed assessment was late. Corporate MDS Support stated the unfinished portions of the quarterly assessments were the social services sections and that the facility had been down to one social worker since December, with another social worker leaving on 01/16/26. Corporate MDS Support also stated they were aware the social services sections were being completed late. The NHA stated the facility had 1.5 MDS nurses, had been approved for another full-time MDS nurse, and had identified the late completion issue, including issuing discipline to the MDS Coordinator for not completing the MDS timely.
Respiratory Equipment Not Dated or Properly Stored
Penalty
Summary
Safe and sanitary respiratory care was not maintained for residents receiving oxygen and nebulizer therapy. During observations of residents with COPD and other chronic conditions, oxygen tubing and humidification canisters were repeatedly found without dates of initiation, including for residents who were observed wearing oxygen via nasal cannula in their rooms. The residents reviewed included individuals with moderate cognitive impairment and diagnoses such as COPD, CHF, AFIB, CKD, diabetes, anemia, chronic respiratory failure, and a hip fracture with replacement. For one resident, a nebulizer medication chamber and mouthpiece were observed stored on a bedside chair in contact with personal items, including shoes, a stuffed toy, and a hand grabber tool. The resident had an order for ipratropium-albuterol nebulizer treatments for shortness of breath and an order that the mask and tubing be cleaned weekly and stored in a clean setup bag. The observation showed the chamber and mouthpiece were not stored in the manner described in the facility's respiratory equipment procedure. The facility's own procedures stated that oxygen tubing should be changed monthly and dated when initiated, that oxygen cannula and tubing should be changed monthly and as necessary, and that nebulizer equipment should be removed, rinsed, dried, and stored in a plastic bag marked with the date and resident name between uses. The infection prevention and control program also stated that the campus would monitor compliance with infection control practices and procedures. Despite these written procedures, the observations and record review showed missing dates on oxygen tubing and humidification canisters for multiple residents and improper storage of nebulizer equipment for one resident.
Missing Physician Code Status Order
Penalty
Summary
The facility failed to ensure comprehensive code status information for one resident, resulting in the absence of a physician order for code status for Resident #76. Resident #76 was admitted most recently with diagnoses including chronic kidney disease, congestive heart failure, heart disease, and dependence on renal dialysis. On 02/10/2026, record review of the EMR showed no physician order present for code status in the order set. During interviews, the Social Worker stated that nurses enter code status orders and that the Social Worker is responsible for code status care plans. The DON stated that the admission nurse enters the code status after obtaining the signed DNR or full code form, and that if a resident is DNR, the facility waits for the physician's signature, with the resident considered full code by default until signed. The DON stated the code status order was missed for Resident #76 because the resident had recently gone to the hospital and all orders were discontinued, but it should have been caught during admission chart review. The facility policy titled, Guidelines for Advanced Directives, states that nursing staff will confirm the desired code status and obtain an order from the physician.
Incomplete Care Plan for Catheter and Bowel Issues
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for Resident #107, who was admitted with diagnoses including diabetes, history of stroke, urinary tract infection, bronchitis, sinusitis, GERD, obstructive and reflex uropathy, hydronephrosis, urinary retention, hypertension, and hypothyroidism. The MDS assessment indicated the resident had full cognitive abilities with a BIMS score of 15/15 and needed some assistance with care. Section H of the MDS showed the resident had an indwelling catheter and was frequently incontinent of bowel, but the care plan only addressed episodes of incontinence related to decreased mobility and did not include bowel or bladder incontinence, diarrhea, constipation, or the indwelling urinary catheter. During observation, the resident stated she had been having frequent diarrhea, had a history of IBS, used Imodium at home, and was unsure what the facility was giving her. She also said the diarrhea was irritating a wound on her buttocks and causing discomfort. The resident was observed with an indwelling catheter and stated she had had a Foley catheter since hospitalization and did not know why she had it. Record review showed nursing notes for catheter malfunction, replacement of the Foley, inability to flush the catheter, no urine output in the bag, and complaints of constipation. The MAR/TAR included Foley care and bowel movement monitoring, and the NP stated the resident had urinary retention, a history of UTIs and hydronephrosis, and had received bowel medications including MiraLAX, Maalox, Senna, and Imodium.
Failure to Provide Timely Vision Services
Penalty
Summary
The facility failed to provide timely vision services for one resident who had diagnoses including cataracts, diabetes mellitus, and hemiplegia and hemiparesis following cerebral infarction affecting the left side. During an interview, the resident was observed wearing glasses and stated they belonged to her deceased husband, that they hurt her eyes, were not comfortable, and that she had asked the facility about seeing vision services but had not been seen yet. She stated she wanted vision services in the facility to get new glasses. Record review and staff interviews showed the resident had signed consent for ancillary services, and the social worker stated residents are signed up for services after the first meeting if they indicate a need. The social worker also stated the resident had consented to being signed on with Health Drive for ancillary services during the resident first meeting, and the nursing home administrator stated that if the resident indicated they wanted services, they would be signed up at that time. The record also showed a care plan for potential impaired vision related to cataracts and presence of intraocular lens, and the facility’s Resident First Meeting Guidelines described the meeting as a time to communicate care needs and seek input from the resident or representative.
Infection Control Failures During Wound Care and in Medication Room
Penalty
Summary
Infection prevention and control standards were not followed during wound care for a resident on Enhanced Barrier Precautions (EBP). The resident had diagnoses including acute post hemorrhagic anemia, COPD, chronic respiratory failure, AFIB, and type II DM, and the MDS showed a BIMS score of 10/15 indicating moderate cognitive impairment. The resident reported a new, sore wound on the bottom that had developed within the past couple of weeks and said dressing changes were being done about every 3 days. The resident’s order called for a foam dressing to the coccyx to be changed every five days and for staff to use EBP, including gown and gloves at minimum during high-contact care activities. During observation of the coccyx wound care, the nurse entered the room without PPE, placed wound care supplies on the resident’s bed tray among the resident’s water, books, and food items, and did not clean the tray or place a barrier on it. The nurse washed hands and put on gloves, but then used the same gloves throughout the procedure without hand hygiene. The nurse opened the foam dressing, removed the old dressing, left the soiled dressing on the bed, and used the same gloves to handle sterile water, gauze, the clean dressing, the resident’s blankets, call light, and bed remote. The wound was cleansed without changing gauze or following a clean-to-dirty method, and the nurse recapped the sterile water bottle after use. The observation also identified a red area of moisture associated skin damage on the right coccyx, about the size of a dime, matching the area the resident described as sore. The nurse stated the area would be reported to the provider and later said the resident was on EBP because of wounds. Interviews with the ICP nurse and wound care nurse confirmed that wound care is a high-contact activity requiring PPE for residents on EBP and that the observed care did not follow infection control standards. The report also identified a separate infection control issue in the 300-hall medication room, where boxes of applesauce, IV antibiotic supplies, and a large empty medication return bag were stacked around the sink and under the soap dispenser, leaving no open counter space for medication preparation or for staff to wash hands without contaminating nearby items. In addition, shared rooms with EBP signs were not initially marked to identify whether bed A or bed B was the resident on EBP, and staff interviews showed inconsistent identification until the signs were later marked.
Expired Supplies and Improper Medication Handling
Penalty
Summary
The facility failed to ensure that expired supplies and medications were properly discarded and stored, leading to expired items being available for use. During a review of the medication storage rooms in various halls, several expired items were found, including sterile gloves, wound dressings, blood collection sets, vacutainers, saline syringes, and intravenous catheters. These findings were confirmed with the Director of Nursing, Director of Sales, and nursing staff. The facility's policy on medication storage did not address procedures for handling expired supplies, contributing to the oversight. Additionally, during a medication administration observation, a nurse was seen improperly handling medications by placing them in a medication cup in the top drawer of a medication cart, which was not double-locked for narcotics. The nurse held medications for residents with abnormal vital signs and mixed them with other residents' medications, using bare hands to sort them. This practice was not documented in the facility's policies, and the nurse was unsure if it was approved by the facility. The improper handling and storage of medications were confirmed during interviews with the Corporate Nurse and the Director of Nursing.
Failure to Prevent Misappropriation of Resident's Money
Penalty
Summary
The facility failed to prevent the misappropriation of a resident's property, resulting in a resident missing $448. The resident, who had full cognitive abilities, reported that the money was missing from her purse, which she kept in a locked bedside drawer. The resident had been provided a key for the drawer, but it was noted that the key was sometimes left on the bedside dresser. The facility's investigation included interviews with the resident, staff, and family, and the local police were contacted. However, the police did not pursue the matter further, and the facility did not initially obtain a police report. The facility's admission inventory list documented the resident's money, but the document was not signed by the resident. The Administrator was not notified of the large amount of money the resident brought into the facility, and the resident was not informed about the option to use the facility's Trust Fund for safekeeping. The facility's policy on abuse and neglect defines misappropriation of property but does not provide clear guidelines for preventing such incidents. The Director of Nursing confirmed that nurse aides completed the inventory list but did not receive training on the Resident's Trust Fund. The facility's admission packet mentioned the Trust Fund but did not offer alternatives for the safe storage of valuables. The facility did not provide education to all staff regarding the incident, and no additional measures were enacted to ensure the safety of resident belongings after the incident.
Deficiencies in Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to ensure safe and sanitary storage of respiratory equipment for three residents and did not provide oxygen as ordered for one resident. Resident #3, who was admitted with multiple diagnoses including heart failure and chronic respiratory failure, was observed using an oxygen concentrator set at 5 liters per minute, contrary to the physician's order of 4 liters per minute. The resident expressed a preference for the higher setting, and the Director of Nursing later provided a revised physician order allowing oxygen between 2-6 liters for comfort. Additionally, a bottle of distilled water used for the oxygen concentrator was found undated and stored on the floor, raising concerns about sanitation. For Residents #272 and #273, the facility did not ensure proper storage and handling of oxygen equipment. Resident #272's nasal cannula was found lying on the bed covers, and there were no care plan interventions related to oxygen use. Similarly, Resident #273's nasal cannula was left on the bed while the concentrator was running, and the resident required assistance with transfers. The facility's policy stated that nursing assistants should not adjust oxygen settings, yet there was no evidence of proper interventions or storage practices being followed, leading to potential exposure to infectious organisms.
Failure to Follow Resident Food Preferences
Penalty
Summary
The facility failed to adhere to a resident's food preferences, resulting in dissatisfaction and reduced breakfast consumption. On January 15, 2025, a resident was observed with a breakfast tray that included a sausage patty, which they did not consume due to a dislike of pork. The resident expressed their displeasure, rating their upset level as 5 out of 10, and stated they had communicated this preference daily. A review of the meal ticket confirmed the resident's dislike for pork. Despite the facility's protocol of triple-checking meal tickets to ensure preferences are followed, this oversight occurred, indicating a lapse in the implementation of the facility's dining services and nutrition support policies.
Infection Control Deficiencies in Hand Hygiene, PPE Use, and Item Storage
Penalty
Summary
The facility failed to adhere to Infection Prevention and Control standards, as evidenced by multiple deficiencies observed during a survey. One deficiency involved improper hand hygiene during medication administration for two residents. Nurse H was observed not performing hand hygiene before donning or after removing gloves while testing a resident's blood sugar level. Additionally, Nurse H handled medications with bare hands, placing them in a medication cup without proper sanitation, which is against the facility's policy. Another deficiency was noted in the use of Personal Protective Equipment (PPE) for a resident in Transmission-Based Precautions. A nurse aide was observed in the resident's room without wearing the required PPE, such as an isolation gown and gloves, and had a surgical mask improperly worn under her chin. Despite signs indicating the need for PPE due to the resident being under Droplet and Contact Precautions, the nurse aide did not comply, increasing the risk of infection transmission. The facility also failed to ensure proper storage of resident care items to prevent contamination. In a shared room, the sink countertop was cluttered with personal and medical items, including a toothbrush and feeding tube supplies, making it impossible to use the sink for hand hygiene without risking water splash contamination. This cluttered environment posed a potential risk for the spread of infection, as the items were exposed to possible contamination from the sink area.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by the experiences of two residents who wished to remain confidential. One resident reported hearing a nurse aide tell another resident to relieve themselves in their brief because the aide was busy, which the resident felt was a dignity issue. This resident also highlighted issues such as a lack of basic supplies, insufficient CNA staffing, poor food quality, and delays in meal service. Additionally, during shift changes, outgoing staff would sometimes refuse to complete tasks, passing them on to the next shift. Another resident expressed feelings of embarrassment and degradation due to the use of inadequate absorbent pads instead of preferred pull-ups, leading to wet sheets. This resident also recounted an incident where an aide left her without oxygen, and when she sought help, she felt dismissed by staff. The resident's daughter corroborated these issues, noting that aides would sometimes turn off call lights without returning to assist, leaving residents without the necessary help. The facility's policies on answering call lights and respecting resident rights were reviewed, revealing that staff did not adhere to guidelines such as answering call lights promptly, providing requested services before turning off call lights, and treating residents with dignity and respect. These failures resulted in residents feeling belittled and discontented, with a fear of accidents due to unaddressed call lights.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 213 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lapeer
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Orchards At Lapeer | 0.8 mi | ★★★★★ | 30 | 0 |
| Lapeer County Medical Care Facility | 1.3 mi | ★★★★★ | 15 | 0 |
| Mclaren Lapeer Region | 1.5 mi | ★★★★★ | 2 | 0 |
| Briarwood Nursing And Rehabilitation | 15.3 mi | ★★★★★ | 7 | 0 |
| Medilodge Of Grand Blanc | 15.4 mi | ★★★★★ | 22 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Stonegate Health Campus.
100% money-back within 48 hours.
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.