Froh Community Home

F 0656 During an interview and record review on 5/20/25 09:41 AM, Guardian CC' reported when the guardianship service received their referral from the facility in October 2023, trauma was not indicated on the referral, and Level of Harm - Minimal harm or they were unaware of care needs. potential for actual harm

During an interview and record review on 5/20/25 3:20 AM, Social Services E stated while reviewing Resident R40's Residents Affected - Few medical record, I do not have an admission trauma assessment form for (Resident R40). I just had a conversation with

the resident. When I do the PHQ-9 (depression/mood) her score was from staff assessment because she could not continue a conversation. There is a Care Plan focus related to neglect under cognition loss and dementia.

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 Resident R22's and Resident 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 .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 7 235345 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Review of Resident R7's Care Plan, dated 5/13/25, with a focus on ADL (activities of daily living) Functional Status/Rehabilitation Potential from a short hospital stay for pulmonary embolism and pneumonia, indicated Level of Harm - Minimal harm or the resident wanted to remain safe using interventions that included using a CPAP at night and removing it in potential for actual harm the morning.

Residents Affected - Few Resident R22

According to the MDS dated [DATE REDACTED], Resident 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 Resident R22 had a non-invasive mechanical ventilator (CPAP).

Review of Resident 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 Resident 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 Resident 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 Resident 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 Resident 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 (Resident R22's) mask. She gets a rash from wearing the mask. The staff should switch the fabric coverings out daily. (Resident R7) still has a mask whether it is a CPAP or BiPAP.

Review of Resident R22's Care Plan for a comprehensive resident-focused treatment of the CPAP machine, did not indicate a treatment plan had been developed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 7 235345 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 48637

Residents Affected - Many Based on observation, interview, and record review, the facility failed to ensure proper label and dating of foods and discarding of foods in the kitchen and kitchenette resulting in the potential to spread food borne illness to all residents that consume food from the kitchen.

Findings Include:

During the initial tour of the kitchen with Certified Dietary Manager (CDM) D on 5/19/2025 at 7:49 AM, the walk-in refrigerator was observed to have peaches in a large plastic container with no label and date.

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 .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 7 235345 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Review of Care Plan for Resident #45 revealed problem/goal/approach .start date 3/25/2025 Problem: Enhanced Barrier Precautions .has an MDRO (multi drug resistant organism) . acute or colonization, Level of Harm - Minimal harm or requiring enhanced barrier precautions . goal: to provide a safe sanitary and comfortable environment to help potential for actual harm prevent the development and transmission of communicable diseases and infections. Reduce the transmission of resistant organisms. Resident to show no signs & symptoms of infection .Approach: Gown Residents Affected - Few and gloves to be worn during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing.

In an interview on 5/21/25 at 1:31 pm, Assistant Director of Nursing/Infection Preventionist (ADON/IP) I reported that Resident #45 was in enhanced barrier precautions and that her expectations were that staff wore PPE during high contact care activities. ADON/IP I reported linen changes were high contact care activities, and that CNA T should have worn PPE when she was making Resident #45's bed.

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 .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 7 235345