Stonegate Health Campus

In the surveyor’s words

From the most serious findings on record at Stonegate Health Campus, in the surveyor’s own words.

• Actual harm, isolatedF686Jan 9, 2024

  Based 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. […]

• Actual harm, isolatedF689Jan 9, 2024

  This 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. […]

• Actual harm, isolatedF686Oct 10, 2022

  Based on interview and record review, the facility failed to ensure pressure ulcer interventions were provided per professional standards to prevent the worsening of a wound for one resident (Resident #169) of 3 residents reviewed for pressure ulcers, resulting in Resident #169 developing an Unstageable pressure ulcer with 80% of the wound covered in slough (dead, stringy tissue), with irregular, macerated (the softening and breaking down of skin as a result of prolonged exposure to moisture) wound edges, resulting in discomfort, frustration and potential infection. […]

• Actual harm, isolatedF689Oct 10, 2022

  Based on observation, interview and record review, the facility 1) Failed to ensure that safe practices were in place to prevent a burn from hot coffee for one resident (Resident #14) and 2.) Failed to ensure fall that prevention measures were developed and implemented to prevent a fall for one resident (Resident #218), resulting in Resident #14 sustaining a burn injury on his right thigh without additional measures to ensure all residents were protected from similar burn injuries and Resident #218 falling without preventive measures identified and implemented to aid in preventing additional falls and a fracture to the hand. […]

• Actual harm, isolatedF684Sep 15, 2022

  This Citation Pertains to Intake MI 840. Based on interview and record review, the facility failed to implement and operationalize policies and procedures to ensure care coordination and timely response to a change in condition for one resident (Resident #701) of three residents reviewed, resulting in a lack of care coordination for scheduled blood transfusion, a delay in transfer to the hospital for emergency treatment with subsequent necessary surgical interventions due to a bowel obstruction (potential life threatenng condition where digested material is unable to move through the intestines), [CONDITION(S)] (surgically created opening in the abdomen to allow for the passage of stool), and the likelihood for infection and decline in overall health status. […]