Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 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.
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.
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.
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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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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 | — | 0 | 0 |
| Briarwood Nursing And Rehabilitation | 15.3 mi | — | 4 | 0 |
| Medilodge Of Grand Blanc | 15.4 mi | — | 19 | 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 August 2026) and official state health department websites.