Froh Community Home
Froh Community Home in Sturgis, MI — inspection on May 21, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview and record review on 5/21/25 at 9:49 AM, Director of Nursing (DON) B stated, A trauma assessment should be done for each resident. It would be in the Observation part of the medical records and titled Trauma Informed Observation.
This form should be done within the first 14-days of a resident admitting. DON B reviewed R22's and R40's medical chart stating there was not a formal trauma assessment completed upon admission for either resident and No starting point for treatment. I don't know how the resident would be cared for if an assessment with their needs was not completed.
Review of facility policy Trauma Informed Care dated 3/11/25, revealed, Goal: It is the policy of (name of facility) to ensure residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice .Trauma is defined as an event, a series of events, or set of circumstances experienced by an individual as physically or emotionally harmful or life-threatening, that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being .Trauma-Informed Care is defined as an organizational structure and treatment framework that involves understanding, recognizing, and responding to effects of all types of trauma .Procedures: Each resident will be screened for a history of trauma within 14-days of admission by Social Service Director or designee .
235345
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 235345 B.
Wing 05/21/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Froh Community Home 307 N Franks Avenue Sturgis, MI 49091
According to the MDS dated [DATE], R22 scored 5/15 on her BIMS, indicating she was cognitively impaired with diagnoses that included dementia, partial paralysis, and Parkinson's disease.
Section O-Special Treatments and Programs indicated R22 had a non-invasive mechanical ventilator (CPAP).
Review of R22's Order Summary dated 1/29/25 revealed,
-Apply CPAP at bedtime and remove it in the morning.
Twice A Day 06:00 - 14:00, 19:00 - 22:00
-Clean CPAP Daily per policy.
Remove facial oils from mask by wiping with damp cloth and mild soap, rinse with warm tap water.
Once A Day 06:00 - 14:00
Observed on 5/19/25 at 10:26 AM, a CPAP machine was at R22's bedside with the mask covered with a fitted blue fabric.
The mask was lying on personal items without being protected from dust and debris.
Observed on 5/20/25 at 9:36 AM, a CPAP machine was at R22's bedside with the mask covered with a fitted blue fabric.
The mask was lying on personal items without being protected from dust and debris.
Observed on 5/20/25 at 2:30 PM, a CPAP machine was at R22's bedside with the mask covered with a fitted blue fabric.
The mask was lying on personal items without being protected from dust and debris.
Observed on 5/20/25 at 9:30 AM, a CPAP machine was at R22's bedside with the mask covered with a fitted blue fabric.
The mask was lying on personal items without being protected from dust and debris. with a stuffed animal on top of the mask.
During an interview and record review on 5/21/25 at 10:45 AM, Infection Preventionist (IP) I stated, A CPAP should be cleaned as ordered to protect the resident from respiratory infection.
There is a policy for cleaning CPAPs.
During an interview and record review on 5/21/25 at 9:39 AM, Director of Nursing (DON) B reviewed facility policy, The Cleaning of the C-PAP System (approved 2/10/2021), stating, The CPAP is cleaned daily wipe mask down with mild soap. I would think they (mask) would be in a bag to protect it and keep it clean. I ordered the fabric coverings for (R22's) mask.
She gets a rash from wearing the mask.
The staff should switch the fabric coverings out daily. (R7) still has a mask whether it is a CPAP or BiPAP.
Review of R22's Care Plan for a comprehensive resident-focused treatment of the CPAP machine, did not indicate a treatment plan had been developed.
235345
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 235345 B.
Wing 05/21/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Froh Community Home 307 N Franks Avenue Sturgis, MI 49091
During the full kitchen tour with CDM D, Chef Manager (CM) C and Food Service Regional Director of Operations (RDO) BB on 5/20/2025 at 8:28 AM, the following was observed:
The walk-in refrigerator contained a plastic container with yogurt with an open date of 5/17 and expiration date of 5/19.
The reach-in refrigerator contained an open half gallon 2% milk jug with an open date of 5/17 and expiration date of 5/19.
The reach in refrigerator also contained an open half gallon 2% milk jug with no label and date.
On 5/20/2025 at 9:00 AM, the kitchenette by Maple and Oak Halls were observed to have an open bag of potato chips that was not sealed and did not have a label and date.
According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days.
The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety .
235345
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 235345 B.
Wing 05/21/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Froh Community Home 307 N Franks Avenue Sturgis, MI 49091
Review of facility policy Transmission Based Precautions Enhanced Barrier Precautions with a revision date of 5/19/2024 revealed .1.
Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities.
High care activities include. changing linens .
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