Stonegate Health Campus

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area, resulting in the potential to spread food borne illness to all residents who consume food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were completed timely for six residents (R5, R6, R8, R17, R64, R84) of seven residents reviewed for MDS assessments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary practices were followed for respiratory equipment including changing/dating oxygen tubing and humidification canisters for four residents (R5, R7, R19 and R81) and the storage of a nebulizer treatment chamber and mouthpiece for one resident (R5) of five residents reviewed for respiratory care.

Inspectors wroteBased on interview and record review, the facility failed to ensure comprehensive code status information for one resident (Resident #76,) of four residents reviewed for code status, resulting in a lack of a physician's order for code status for (R76).

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement comprehensive care plans for 1 resident (Resident #107) of 22 residents reviewed, resulting in Resident #107 lacking Care Plans for an indwelling urinary catheter and bowel and bladder incontinence related to diarrhea and constipation, which could lead to the resident lacking necessary care and services. Findings Include: Resident #107: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #107 was admitted to the facility on [DATE] with diagnoses: Diabetes, history of a stroke, urinary tract infection, bronchitis, sinusitis, GERD, obstructive and reflex uropathy (bladder dysfunction), hydronephrosis (kidney disease), urinary retention, hypertension and hypothyroidism. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide timely vision services for one resident (Resident #17) of two residents reviewed for vision services.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure Infection Prevention and Control standards of practice were followed for 1.) Personal Protection Equipment/PPE use and hand hygiene during wound care for one resident (Resident #7) in Enhanced Barrier Precautions, and 2.) the 300 Hall Medication room had a lack of access to the sink to perform hand washing, including IV supplies for one resident (Resident #14) stored under the soap dispenser. Findings Include: Medication room [ROOM NUMBER] Hall: On 2/10/2026 4:29 PM, during a tour of the 300-hall medication room with Nurse N, 2 large carboard boxes of apple sauce were observed stacked on the counter next to the sink. Both were underneath the soap dispenser. In addition, bags of IV antibiotic supplies for a resident were stacked on top of the applesauce boxes. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure expired supplies were discarded and ensure that medications to be discarded were stored properly, resulting in expired supplies and medications to be discarded being available for use and consumption.

Inspectors wroteThis Citation Pertains to Intake # MI00148568 Based on interview and record review the facility failed to prevent misappropriation of resident property for one resident (#218) of one reviewed for abuse, resulting in Resident #218 missing $448.00 while at the facility. Findings Include: Resident #218 Personal Property A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #218 was admitted to the facility on [DATE] with diagnoses: Crohn's disease, colitis, acute kidney failure, chronic kidney disease, atrial fibrillation, arthritis, neuropathy, hearing loss, history of a mini stroke. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status score of 15/15 and the resident needed some assistance with care. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure safe and sanitary storage of respiratory equipment for 3 residents (#3, #272, and #273)) and ensure oxygen was provided as ordered for 1 resident (#3) of 3 residents reviewed for respiratory care, resulting in the potential for exposure to infectious organisms for Residents #3, #272 and #273 and inappropriate treatment with potential for adverse reactions for Resident #3. Findings Include: Resident #3 Respiratory Care A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #3 was admitted to the facility on [DATE] with diagnoses: Heart failure, chronic respiratory failure, COPD, diabetes, morbid obesity, and obstructive sleep apnea. The resident had a Brief Interview for Mental status/BIMS score of 15/15, indicating full cognitive abilities. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that food preferences were followed for one resident (Resident #271) of three residents reviewed for food preferences, resulting in unhappiness and decreased breakfast consumption.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Infection Prevention and Control standards of practice were followed for 1). Hand Hygiene during medication administration for 2 residents (#'s 40, #42); 2.) Personal Protective Equipment/PPE use for 1 resident (#38) in Transmission Based Precautions; and 3.) storage of resident care items to prevent water splash and contamination from the resident room sink for Resident #22, resulting in the potential for spread of infection, which could cause serious illness. Findings Include: FACILITY Infection Control Resident #22 A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #22 was admitted to the facility on [DATE] with diagnoses: history of a stroke, left sided weakness, difficulty swallowing, feeding tube, history of respiratory failure, anxiety, depression, and neuropathy. [...]

Inspectors wroteThis Citation pertains to Intake Numbers MI00142107 and MI00144987. Based on observation, interview, and record review, the facility failed to ensure that residents were treated in a respectful and dignified manner for two residents (Confidential Resident #1 and Confidential Resident #2), who wished to remain as a confidential group of residents, from a facility census of 71 residents, resulting in a fear of accidents occurring due to call lights not being answered timely or call lights being turned off without completing the nursing task required, and residents' verbalizations of feelings of a lack of dignity, belittlement and discontentment.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and operationalize procedures for pressure ulcer (wounds caused by pressure) assessment, documentation, and management for one resident (Resident #272) of one resident reviewed, resulting in a lack of accurate and timely assessments, lack of implementation of meaningful interventions, and Resident #272 developing two unstageable (full thickness tissue loss with unknown depth) pressure ulcers and a Stage two (partial thickness loss of tissue presenting as a shallow open ulcer with a red pink wound bed, without slough) pressure ulcer, unnecessary pain, the likelihood for additional wound development/progression, and decline in overall health status.

Inspectors wroteThis Citation pertains to Intake Numbers MI00138100 and MI00137191. Based on observation, interview and record review, the facility failed to 1.) Prevent an unauthorized exit for Resident #222, 2.) Follow a care-planned transfer status for Resident #1, and 3.) Follow standards of practice with a removal of a sling underneath Resident #5 for three residents (Resident #1, Resident #5 and Resident #222) of six residents reviewed for accidents, supervision and falls, resulting in Resident #222 exiting the building without supervision with the potential for injury and bodily harm; Resident #1 sustaining a fracture, surgery and pain to the left lower leg, and decreased mobility; and Resident #5 with a fracture to the left thigh, pain and decreased mobility.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and operationalize a comprehensive infection control program, encompassing outcome and process surveillance, accurate data collection/documentation/analysis and failed to ensure Personal Protective Equipment (PPE) use for transmission-based isolation precautions resulting in a lack of accurate and comprehensive infection control tracking, surveillance and data monitoring/analysis and the likelihood for spread of microorganisms and illness to all 64 facility residents.

Inspectors wroteThis Citation pertains to Intake Number MI00137963. Based on observation, interview and record review, the facility failed to ensure the provision of Activities of Daily Living (ADL) care per residents' care needs and care plans for five residents (Resident #4, Resident #6, Resident #35, Resident #56, and Resident #272 ) of five residents reviewed, resulting in a lack of communication and knowledge of resident ADL care assistants' needs, lack of timely and appropriate ADL care per residents' needs and care plans, and the likelihood for the provision of an inappropriate level of assistance, unmet care needs, injury, and feelings of confusion and frustration.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide timely assistance and accessible call lights for two residents (Resident #20 and Resident #30) of three residents reviewed, resulting in a lack of timely care, residents yelling out for assistance, call lights not being in reach, and verbalization of feelings of humiliation and frustration.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the provision of residents' rights were provided prior to or upon admission for one resident (Resident #272) of one resident reviewed, resulting in a delay of communication and receipt of residents' rights verbally or in writing, lack of Resident and/or Representative knowledge of rights, responsibilities, and a plan of care, verbalization of lack of knowledge, and the potential for misinterpretation and violation of residents' rights.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a baseline care plan for edema was created upon admission for one resident (Resident #272) of one resident reviewed resulting in a lack of monitoring, interventions, and the potential for unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility to ensure that care plans were revised for one resident (Resident #57) of four residents reviewed, resulting in care plans not accurately reflecting current healthcare providers' orders, lack of staff communication, and the likelihood for the provision of inappropriate care, unmet care needs, and injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and operationalize policies and procedures of indwelling urinary catheter care for one resident (Resident #272) of two residents reviewed, resulting in inappropriate positioning of indwelling urinary catheter drainage tubing and bags and the likelihood for dislodgement, injury, infection, and decline in overall health status.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow a physician's diet orders for one resident (Resident #4), resulting in no fortified shake on the breakfast tray with the likelihood of continued weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure cleaning of a CPAP machine for one resident (Resident #1) of two residents reviewed for oxygen and respiratory care , resulting in the potential for harborage of infectious organisms and respiratory infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to safely secure medications and ensure Narcotic reconciliation was completed, resulting in the 300-Hall medication cart being left unlocked and unattended; incomplete and scribbled out numbers on the 200-Hall narcotic reconciliation sheets with the likelihood of narcotic diversion going unnoticed.

Inspectors wroteBased on interview and record review, the facility failed to ensure a non-viable TSH lab draw was followed up on and a Levothyroxine medication was given per standards of practice for one resident (Resident #14), resulting in a TSH level of 7, Levothyroxine given along with Calcium with the further likelihood of decreased absorption of the medication and increased signs and symptoms of Hypothyroidism.