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)
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
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
80
Certified beds
Average residents
73
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
Staffing
Hours and turnover
RN hours / resident day
0.74
Registered nurse staffing
LPN hours / resident day
0.95
Licensed practical nurse staffing
Aide hours / resident day
2.79
Nurse aide staffing
Weekend hours
3.80
Weekend nurse staffing
RN turnover
33%
Annual RN turnover
Total nurse turnover
49%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
Survey summary
Recent inspection cycles
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
D · Potential for more than minimal harm
2022-10-10
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 2022-10-28
D · Potential for more than minimal harm
2022-10-10
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-10-10
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-10-10
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-10-10
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-10-10
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 2022-10-28
D · Potential for more than minimal harm
2022-10-10
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 2022-10-28
D · Potential for more than minimal harm
2022-10-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-10-10
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-10-10
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-10-10
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 2022-10-28
D · Potential for more than minimal harm
2022-10-10
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-10-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-10-10
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-10-10
F728 · Nursing and Physician Services Deficiencies
Health
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-10-10
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-10-10
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-10-10
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 2022-10-28
D · Potential for more than minimal harm
2022-10-10
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2022-10-28
Penalties and ownership
What sits behind the stars
$66,414
2024-01-09
Fine
Fine · fine $66,414
Fine
$0
2024-01-09
Payment Denial
Payment Denial · denial start 2024-02-09 · 34 days
34 day denial
Ownership
Trilogy Opco LLC
5% Or Greater Direct Ownership Interest · Organization
American Healthcare Reit Holdings LP
5% Or Greater Indirect Ownership Interest · Organization
American Healthcare Reit Inc
5% Or Greater Indirect Ownership Interest · Organization
Badia, Marcus
Operational/Managerial Control · Individual
Barney, Leigh
Corporate Officer · Individual
Bryant, William
Corporate Officer · Individual
Bufford, Randall
Corporate Officer · Individual
Conner, Gregory
Corporate Officer · Individual
Continental Merger Sub LLC
5% Or Greater Indirect Ownership Interest · Organization
Corbin, Kathy
W-2 Managing Employee · Individual
Davis, David
Corporate Officer · Individual
Fightmaster, Lisa
W-2 Managing Employee · Individual
Gahc3 Trilogy Jv LLC
5% Or Greater Indirect Ownership Interest · Organization
Gahc4 Trilogy Jv LLC
5% Or Greater Indirect Ownership Interest · Organization
Keybank National Association
5% Or Greater Mortgage Interest · Organization
Northstar Healthcare Income Inc
5% Or Greater Indirect Ownership Interest · Organization
Northstar Healthcare Income Operating Partnership LP
5% Or Greater Indirect Ownership Interest · Organization
Prosky, Danny
Corporate Officer · Individual
Streiff, Mathieu
Corporate Officer · Individual
Trilogy Healthcare Holdings Inc
5% Or Greater Indirect Ownership Interest · Organization
Trilogy Holdings Nt-Hci, LLC
5% Or Greater Indirect Ownership Interest · Organization
Trilogy Investors LLC
5% Or Greater Indirect Ownership Interest · Organization
Trilogy Management Services LLC
Operational/Managerial Control · Organization
Trilogy Real Estate Investment Trust
5% Or Greater Indirect Ownership Interest · Organization
Trilogy Reit Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
The Orchards at Lapeer
Lapeer, MI
2-star overall rating with 3-star inspections with 13 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Lapeer County Medical Care Facility
Lapeer, MI
4-star overall rating with 3-star inspections with $68,445 in total fines with 14 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
McLaren Lapeer Region
Lapeer, MI
5-star overall rating with 4-star inspections with 2 recent health deficiencies
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