Froh Community Home

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 6/9/26 starting at 6:30 AM, an initial tour of the kitchen was performed with Dietary Manager (DM) K.On 6/9/26 at 6:44 AM, observation of the produce and preparation walk in cooler found a large three-gallon stock pot labeled sweet potato soup. The item was found covered in plastic wrap, with noticeable condensation on the inside top. When asked when this item was prepared, DM K stated it was made last evening and cooled down with an ice wand. When asked what temperature the soup should be at this time, DM K stated it should be at 41F or below. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents received annual Level 1 PASARR (Pre-admission Screening and Resident Review) and follow up Level II PASARR to ensure appropriate mental health services were provided for 5 residents (Resident #10, Resident #17, Resident #20, Resident #48, Resident #8) of 5 residents reviewed for PASARR resulting in the potential for residents to not receive appropriate mental health treatment and services and residents to be inappropriately placed in the nursing facility .

Inspectors wroteBased on interview, and record review, the facility failed to ensure psychotropic medications (prescription drugs that alter brain chemistry to affect mood, thoughts, behavior and perception) were not prescribed and administered without a medical indication for use for 1 (Resident #4) of 6 residents reviewed for chemical restraints, resulting in the potential for a resident to receive psychotropic medications unnecessarily.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide individualized activities designed to meet the interests and support the mental and psychosocial well-being of 1 (Resident #9) of 1 resident reviewed for activities, resulting in boredom, decreased mental stimulation and decreased satisfaction with personal leisure lifestyle.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure effective pain medication was provided prior to wound care treatments for 1 (Resident #4) of 1 resident reviewed for pain management, resulting in 1. Resident #4 undergoing wound measurements and dressing changes without his requested pain medication. 2. Resident #4 grimacing, verbalizing pain and expressing frustration that he did not receive the pain medication he requested.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Trauma Care Assessment was completed and care plan developed to mitigate triggers of trauma in 2 of 2 residents (R22 and R40) reviewed for history of trauma, resulting in the potential for unidentified re-traumatization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure cleaning of respiratory equipment for two (R7 and R22) of two residents reviewed for respiratory care, resulting in the potential of harboring bacteria and pathogens causing infection in a vulnerable population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the use of person protective equipment (PPE) (gown and gloves) by staff during high contact care activities for 1 (Resident #45) of 5 residents reviewed for enhanced barrier precautions (EBP) resulting in the potential for the spread of infection, cross contamination, and disease transmission.

Inspectors wroteBased on interview and record review, the facility failed to ensure that Quality Assessment and Assurance (QAA) meetings were held at least quarterly in a census of 62 residents, resulting in the potential for quality deficiencies not being identified or corrected.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper infection control protocols and practices that included Enhanced barrier precautions (EBP) and/or transmission based precautions per national standards of practice for 5 of 17 residents (#31, #50, #27, #261, #262, #5), 2. ensure adequate hand hygien and hygenic wound care for 1 of 1 resident, and 3. ensure no consumption of personal beverages in resident care areas, resulting in the increased potential for the spread of infection, bacterial harborage, cross contamination, and disease transmission for residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to offer the pneumococcal vaccine for 4 (Resident #26, #50, #38, #24) of 5 residents reviewed for immunizations, resulting in a delay in the residents being given the opportunity to receive or decline the pneumococcal vaccination.

Inspectors wroteBased on observation and interview the facility failed to preserve resident dignity in the dining room during meal service for 3 (Resident #5, Resident #17, and Resident #22) of 17 residents reviewed for dignity resulting in the potential for a reasonable person to experience feelings of embarrassment, shame, and/or a loss of self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of transfer for 1 of 3 residents (Resident #50) reviewed for hospitalizations, resulting in the potential for residents and/or resident representatives being uninformed of the reason for transfer and their rights.

Inspectors wroteBased on interview and record review the facility failed to ensure that a licensed pharmacist completed a monthly medication regimen review for 1 (Resident #28) of 6 residents reviewed for unnecessary medication use resulting in the potential for medication irregularities in the indication for use, excessive dosage, adverse reactions, and/or medication errors.

Inspectors wroteBased on interview and record review the facility failed to ensure that residents of the facility were free from unnecessary psychotropic medication use in 1 (Resident #28) of 6 residents reviewed for unnecessary medication use resulting in incomplete monitoring of the use, potential adverse reactions, and dosage adjustments of an as needed psychotropic medication.