Lapeer, MI

Stonegate Health Campus

3-star overall rating with 3-star inspections with $66,414 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

2525 Demille Road, Lapeer, MI

(810) 245-9300

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Trilogy Health Services

Operator or chain grouping

Approved since

2013-01-11

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

125 facilities

Chain averages 4 overall / 3 health / 3 staffing / 5 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.74

Registered nurse staffing · state 0.77 · national 0.68

LPN hours / resident day

0.95

Licensed practical nurse staffing · state 0.88 · national 0.87

Aide hours / resident day

2.79

Nurse aide staffing · state 2.38 · national 2.35

Total nurse hours

4.48

All reported nurse hours · state 4.03 · national 3.89

Licensed hours

1.69

RN + LPN hours · state 1.65 · national 1.54

Weekend hours

3.80

Weekend nurse staffing · state 3.52 · national 3.43

Weekend RN hours

0.45

Weekend registered nurse coverage · state 0.49 · national 0.47

Physical therapist

0.06

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.68

CMS adjusted RN staffing hours

Adjusted total hours

4.11

CMS adjusted total nurse staffing hours

Case-mix index

1.49

Higher values indicate more complex resident acuity

RN turnover

33%

Annual RN turnover · state 41% · national 45%

Total nurse turnover

49%

Annual nurse turnover · state 44% · national 46%

SNF VBP

Value-based purchasing

Program rank

6,180

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

33.75

Composite VBP score used to determine payment impact.

Payment multiplier

0.9879

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

1.58

Baseline 18.44% · Performance 20.70% · Measure score 1.58 · Achievement 1.58 · Improvement 0

Healthcare-associated infections

5.28

Baseline 8.43% · Performance 6.44% · Measure score 5.28 · Achievement 4.65 · Improvement 5.28

Total nurse turnover

3.35

Baseline 34.12% · Performance 50.00% · Measure score 3.35 · Achievement 3.35 · Improvement 0

Adjusted total nurse staffing

3.29

Baseline 3.60 hours · Performance 4.01 hours · Measure score 3.29 · Achievement 3.29 · Improvement 1.39

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	12.43%	10.72% 1.7 pts worse	No Different than the National Rate · Eligible stays 188 · Observed rate 14.36% · Lower 95% interval 9.81%
Discharge to community	58.8%	50.57% 8.2 pts better	Better than the National Rate · Eligible stays 191 · Observed rate 54.45% · Lower 95% interval 51.7%
Medicare spending per beneficiary	0.99	1.02 About the same
Drug regimen review with follow-up	99.12%	95.27% 3.9 pts better	Numerator 113 · Denominator 114
Falls with major injury	0.88%	0.77% 0.1 pts worse	Numerator 1 · Denominator 114
Discharge self-care score	27.78%	53.69% 25.9 pts worse	Numerator 25 · Denominator 90
Discharge mobility score	41.11%	50.94% 9.8 pts worse	Numerator 37 · Denominator 90
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 114 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	6.45%	7.12% 0.7 pts better	No Different than the National Rate · Eligible stays 113 · Observed rate 5.31% · Lower 95% interval 3.83%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 125
Staff flu vaccination coverage	14.12%	42% 27.9 pts worse	Numerator 25 · Denominator 177
Discharge function score	36.67%	56.45% 19.8 pts worse	Numerator 33 · Denominator 90
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 58 · Denominator 58
Transfer of health information to patient	96.77%	96.28% 0.5 pts better	Numerator 30 · Denominator 31
Resident COVID-19 vaccinations up to date	28.81%	25.2% 3.6 pts better	Numerator 17 · Denominator 59

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.8	1.7 0.1 pts worse	1.9 0.1 pts better	Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.0 · Expected 2.1 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.1	1.5 0.4 pts better	1.8 0.7 pts better	Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.0 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.0%	95.0% 4 pts better	93.4% 5.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.0% · Q3 100.0% · Q4 98.0% · 4Q avg 99.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	95.0% 5 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	4.2%	3.1% 1.1 pts worse	3.3% 0.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 6.0% · Q3 2.3% · Q4 2.0% · 4Q avg 4.2% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.9%	4.1% 2.2 pts better	11.4% 9.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 8.3% · Q4 0.0% · 4Q avg 1.9%
Percentage of long-stay residents who lose too much weight	3.3%	5.5% 2.2 pts better	5.4% 2.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 5.1% · Q3 5.9% · Q4 0.0% · 4Q avg 3.3%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	20.8%	19.6% 1.2 pts worse	19.6% 1.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 21.4% · Q3 25.7% · Q4 19.5% · 4Q avg 20.8%
Percentage of long-stay residents who received an antipsychotic medication	12.5%	16.5% 4 pts better	16.7% 4.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 6.2% · Q3 13.8% · Q4 13.5% · 4Q avg 12.5% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	15.5%	13.9% 1.6 pts worse	16.3% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 15.5% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	10.7%	11.7% 1 pts better	14.9% 4.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 22.5% · Q3 9.4% · Q4 2.6% · 4Q avg 10.7% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.9% 0.9 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.5%	1.7% 1.2 pts better	1.7% 1.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	23.8%	20.4% 3.4 pts worse	19.8% 4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 32.2% · Q3 22.1% · Q4 14.2% · 4Q avg 23.8%
Percentage of long-stay residents with pressure ulcers	3.7%	5.6% 1.9 pts better	5.1% 1.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 5.2% · Q3 2.6% · Q4 4.0% · 4Q avg 3.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	97.1%	82.8% 14.3 pts better	81.7% 15.4 pts better	Short Stay · 2024Q4-2025Q3 · Q1 96.8% · Q2 98.5% · Q3 97.6% · Q4 95.8% · 4Q avg 97.1%
Percentage of short-stay residents who had an outpatient emergency department visit	11.1%	11.5% 0.4 pts better	12.0% 0.9 pts better	Short Stay · 20240701-20250630 · Adjusted 11.1% · Observed 10.4% · Expected 10.5% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.4%	1.3% 0.1 pts worse	1.6% 0.2 pts better	Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.6% · Q3 1.5% · Q4 1.6% · 4Q avg 1.4% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	97.6%	79.5% 18.1 pts better	79.7% 17.9 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 97.6%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	30.4%	24.2% 6.2 pts worse	23.9% 6.5 pts worse	Short Stay · 20240701-20250630 · Adjusted 30.4% · Observed 29.6% · Expected 23.1% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-01-16 · Fire 2025-01-16

4 health deficiencies

Top issue: Infection Control (1 deficiency)

1 fire-safety deficiencies

Top issue: Services (1 deficiency)

Cycle 2 Health 2024-01-09 · Fire 2024-01-09

15 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2022-10-10 · Fire 2022-10-10

28 health deficiencies

Top issue: Quality of Life and Care (9 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-01-16

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2025-02-24

F · Potential for more than minimal harm 2022-10-10

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-12-08

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-01-16

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2025-02-12

D · Potential for more than minimal harm 2025-01-16

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2025-02-12

D · Potential for more than minimal harm 2025-01-16

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-02-12

D · Potential for more than minimal harm 2025-01-16

F806 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Corrected 2025-02-12

D · Potential for more than minimal harm 2025-01-16

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-02-12

D · Potential for more than minimal harm 2024-09-19

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-10-17

G · Actual harm 2024-01-09

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-03-14

G · Actual harm 2024-01-09

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-02-08

F · Potential for more than minimal harm 2024-01-09

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-02-08

E · Potential for more than minimal harm 2024-01-09

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2024-02-08

D · Potential for more than minimal harm 2024-01-09

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-02-08

D · Potential for more than minimal harm 2024-01-09

F572 · Resident Rights Deficiencies

Health

Give residents a notice of rights, rules, services and charges.

Corrected 2024-02-08

D · Potential for more than minimal harm 2024-01-09

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2024-02-08

D · Potential for more than minimal harm 2024-01-09

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2024-02-08

D · Potential for more than minimal harm 2024-01-09

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2024-02-08

D · Potential for more than minimal harm 2024-01-09

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-02-08

D · Potential for more than minimal harm 2024-01-09

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-02-08

D · Potential for more than minimal harm 2024-01-09

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-02-08

D · Potential for more than minimal harm 2024-01-09

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2024-02-08

E · Potential for more than minimal harm 2023-06-07

F553 · Resident Rights Deficiencies

Health

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Corrected 2023-06-30

E · Potential for more than minimal harm 2023-06-07

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2023-06-30

D · Potential for more than minimal harm 2023-06-07

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2023-06-30

D · Potential for more than minimal harm 2023-06-07

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2023-06-30

D · Potential for more than minimal harm 2023-06-07

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-06-30

C · Minimal harm 2023-06-07

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2023-06-30

G · Actual harm 2022-10-10

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2022-10-28

F · Potential for more than minimal harm 2022-10-10

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2022-10-28

F · Potential for more than minimal harm 2022-10-10

F882 · Infection Control Deficiencies

Health

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Corrected 2022-10-28