Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Froh Community Home during CMS and state inspections, most recent first.
Surveyors observed that food items in the kitchen and kitchenette, including peaches, yogurt, milk, and potato chips, were not properly labeled, dated, or discarded according to FDA Food Code requirements. This failure created the potential for foodborne illness among residents consuming food from these areas.
Two residents with histories of trauma and cognitive impairment did not receive required trauma care assessments or individualized care plans. Staff confirmed that trauma assessments were not completed upon admission, and care plans addressing trauma needs were either delayed or missing, despite facility policy requiring trauma screening within 14 days.
Two residents requiring CPAP therapy were found with their respiratory equipment improperly cleaned and stored, with masks left exposed to dust and debris on personal items at the bedside. Staff interviews revealed confusion about cleaning responsibilities, and daily cleaning procedures outlined in physician orders and facility policy were not consistently followed or documented. One resident's care plan also lacked a comprehensive treatment plan for CPAP use.
Staff did not use required PPE, including gowns and gloves, during high-contact care activities for a resident with an MDRO who was under enhanced barrier precautions. Despite care plan orders and facility policy, a CNA was observed making the resident's bed without PPE, and there was confusion among staff regarding the need for precautions and proper signage.
A fire alarm pull box at the activities west exit door was found to be obstructed and not immediately accessible during an observation, in violation of NFPA 70 and NFPA 72 requirements. The Maintenance Director confirmed the finding at the time of the survey.
Surveyors observed missing ceiling tiles in the drop ceiling grid of the wheelchair storage room near the nurse station, which was confirmed by the Maintenance Director. This failure to maintain the ceiling structure could impact the sprinkler system's heat collection process, resulting in noncompliance with NFPA 25 requirements.
Several corridor doors, including those to resident rooms, were unable to close and positively latch due to PPE hangers mounted on top of the doors, preventing them from resisting the passage of smoke as required. This issue was confirmed by the Maintenance Director during surveyor observation and could potentially affect multiple occupants within the smoke compartment.
Surveyors found a hydrocollator machine used for hot pads placed directly on a towel in the therapy area, with the device hot enough to cause burns upon touch. The machine was not installed to prevent ignition of combustibles, as required, and this was confirmed by the Maintenance Director. This deficiency could potentially affect eight occupants in the therapy area.
The facility failed to hold Quality Assessment and Assurance (QAA) meetings at least quarterly as required. The DON could not provide documentation for QAA meetings from September 2023 to January 2024, and the ADON confirmed a canceled meeting in November 2023 that was not rescheduled.
The facility failed to ensure proper infection control protocols, including Enhanced Barrier Precautions (EBP) and hand hygiene, for several residents with wounds, catheters, and infections. Staff did not don PPE, clean equipment, or perform hand hygiene, increasing the risk of infection spread and cross-contamination.
The facility failed to offer the updated pneumococcal vaccines to four residents, resulting in a delay in their opportunity to receive or decline the vaccination. The Infection Preventionist was unaware of the changes to the immunization requirements, leading to the oversight.
The facility failed to preserve resident dignity during meal service, leaving three residents who required assistance with eating to wait up to 40 minutes while others around them were served and consumed their meals. Staff interviews confirmed that the dining room service process led to these residents being served last, causing them to watch their tablemates eat while they waited.
The facility failed to provide a written notice of transfer for a resident hospitalized due to a myocardial infarction, resulting in the potential for residents and/or their representatives being uninformed of the reason for transfer and their rights. Staff interviews revealed a lack of awareness and adherence to the policy requiring a transfer notice.
The facility failed to ensure that a licensed pharmacist completed monthly medication regimen reviews for a resident with vascular dementia, insomnia, and chronic pain. Despite the care plan indicating the need for pharmacy consultant reviews, no reviews were found in the resident's medical record for several months, as confirmed by the Director of Nursing.
The facility failed to ensure that a resident was free from unnecessary psychotropic medication use. The resident was prescribed lorazepam 0.5 mg PRN for anxiety with no end date, contrary to the requirement that PRN psychotropic medications be limited to 14 days. No gradual dose reductions (GDRs) were attempted, and the lack of auditing led to incomplete monitoring of the medication's use and potential adverse reactions.
Failure to Label, Date, and Discard Food Items per FDA Food Code
Penalty
Summary
The facility failed to ensure proper labeling, dating, and discarding of food items in both the main kitchen and a kitchenette, as observed during multiple tours. In the walk-in refrigerator, a large plastic container of peaches was found without any label or date. Additionally, a plastic container of yogurt and an open half-gallon jug of 2% milk were found with open dates of 5/17 and expiration dates of 5/19, while another open half-gallon jug of 2% milk lacked any label or date. In the kitchenette by Maple and Oak Halls, an open bag of potato chips was observed to be unsealed and without a label or date. These findings were confirmed during observations with the Certified Dietary Manager, Chef Manager, and Food Service Regional Director of Operations. The lack of proper labeling, dating, and discarding of food items is not in accordance with the 2022 FDA Food Code, which requires ready-to-eat, time/temperature control for safety foods to be clearly marked with the date by which they must be consumed, sold, or discarded. The failure to follow these standards created the potential for foodborne illness among all residents consuming food from the kitchen.
Failure to Complete Trauma Assessments and Care Plans for Residents with Trauma Histories
Penalty
Summary
The facility failed to complete trauma care assessments and develop corresponding care plans for two residents with known histories of trauma. Both residents were identified on the facility matrix as having PTSD or trauma, and their Minimum Data Set (MDS) assessments indicated cognitive impairment, anxiety, and depression. For one resident, the care plan addressing psychosocial well-being was created several months after admission, and no trauma assessment was found in the medical record. The social services staff confirmed that no trauma assessment had been completed for this resident, despite being aware of her trauma history. For the second resident, the MDS showed she was not cognitively intact and had diagnoses of anxiety and depression. The resident's guardian reported that trauma was not indicated in the facility's referral, and the social services staff acknowledged that no formal trauma assessment was completed upon admission. The Director of Nursing confirmed that trauma assessments should be completed within 14 days of admission and that neither resident had a trauma assessment or a starting point for treatment documented in their records. Facility policy requires trauma screening within 14 days of admission, but this was not followed for these residents.
Failure to Ensure Proper Cleaning and Storage of CPAP Equipment
Penalty
Summary
The facility failed to ensure proper cleaning and storage of respiratory equipment for two residents who required CPAP therapy. One resident, who was cognitively intact and had a history of heart failure and pneumonia, was observed multiple times with a CPAP mask left unprotected on personal items at the bedside, exposed to dust and debris. The resident expressed concern about the cleanliness of the mask and stated that staff assisted with mask removal but was unsure if it was cleaned as required. Staff interviews revealed confusion about cleaning responsibilities, and review of physician orders and care plans confirmed that daily cleaning was required but not consistently performed or documented. Another resident, who was cognitively impaired with diagnoses including dementia, partial paralysis, and Parkinson's disease, was also observed with a CPAP mask covered by a fabric but still left on personal items and exposed to dust and debris. The mask was sometimes covered with a stuffed animal on top. Staff interviews and policy review indicated that the mask should be cleaned daily and protected, with fabric coverings switched out daily due to the resident's skin sensitivity. However, observations showed that these procedures were not consistently followed, and the resident's care plan did not include a comprehensive treatment plan for CPAP use.
Failure to Use PPE During High-Contact Care for Resident on Enhanced Barrier Precautions
Penalty
Summary
Staff failed to use required personal protective equipment (PPE), specifically gowns and gloves, during high-contact care activities for a resident who was under enhanced barrier precautions (EBP) due to a multidrug-resistant organism (MDRO). The resident, a male with severe cognitive impairment and multiple diagnoses including candidal sepsis and diverticulitis with perforation, had physician orders and a care plan in place requiring EBP for high-contact activities such as dressing, bathing, transferring, and changing linens. On one occasion, a CNA was observed making the resident's bed without wearing any PPE, despite the care plan and facility policy specifying that gown and gloves should be used during such activities. Further review revealed inconsistencies in the availability and signage of PPE for the resident. Initially, no signage or PPE was present in or outside the resident's room, but later signage and a PPE supply bin were observed. The CNA involved stated that PPE was only necessary for residents in isolation and believed the resident was no longer under such precautions, indicating a lack of understanding of EBP requirements. The Assistant Director of Nursing/Infection Preventionist confirmed that the resident was still under EBP and that staff were expected to use PPE during high-contact care, including linen changes.
Obstructed Fire Alarm Pull Box at Activities West Exit
Penalty
Summary
The facility failed to ensure that the fire alarm system was tested and maintained in accordance with an approved program as required by NFPA 70 and NFPA 72. During an observation, it was found that the fire alarm pull box located at the activities west exit door was obstructed and could not be immediately accessed. This issue was confirmed through an interview with the facility Maintenance Director at the time of observation. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
Obstructions in front of the Activities fire alarm pull box have been removed. All other pull stations have been inspected and none are obstructed. All pull-station areas will be inspected on a weekly basis by the maintenance department to make sure there are no obstructions preventing access to the pull stations. All Department Managers and Maintenance staff will be inserviced on keeping pull stations free from obstructions. The Maintenance Director will monitor compliance by completing rounds weekly, observing for obstructed pull stations.
Sprinkler System Maintenance Deficiency Due to Missing Ceiling Tiles
Penalty
Summary
The facility failed to maintain and test the automatic sprinkler system in accordance with NFPA 25 requirements. During an observation, surveyors found missing ceiling tiles in the drop ceiling grid within the wheelchair storage room near the nurse station. This deficiency was confirmed through an interview with the Maintenance Director at the time of observation. The absence of ceiling tiles could interfere with the sprinkler system's heat collection process, as required by NFPA 25, 5.2.1. No information about specific residents, their medical history, or their condition at the time of the deficiency is provided in the report.
Plan Of Correction
The ceiling tiles in the wheelchair storage room have been installed. All other areas of the building have been inspected, and no other ceiling tiles are missing. Ceiling tiles will be inspected on a weekly basis by the maintenance department and documented in the preventative maintenance log. The Maintenance Director will monitor compliance by completing rounds weekly, observing for missing ceiling tiles.
Corridor Doors Blocked by PPE Hangers Preventing Smoke Resistance
Penalty
Summary
The facility failed to ensure that corridor doors protecting corridor openings were able to resist the passage of smoke as required by NFPA 19.3.6.3. During observations, it was found that several resident room doors, specifically room #3 in cottonwood hall and rooms #44 and #4 in maple hall, did not close and positively latch. The deficiency was directly caused by personal protective equipment (PPE) hangers that were mounted on the top of these doors, which physically prevented the doors from closing and latching as required. These findings were confirmed during interviews with the facility Maintenance Director at the time of observation. The report notes that this issue could potentially affect 24 occupants within the smoke compartment if the doors fail to prevent the passage of smoke during a fire. The deficiency was identified through direct observation and interview, with no mention of corrective actions or follow-up steps included in the report.
Plan Of Correction
Maintenance removed all over the door hangers and mounted PPE holders with a different method so as not to impede door from having a positive latch. All other doors have been inspected to ensure that no obstructions keep the doors from latching. The maintenance staff will check doors weekly and document checks in the preventative maintenance log. The Maintenance Director will monitor compliance by conducting rounds weekly, observing for door latching issues.
Improper Placement of Hydrocollator Machine Creates Fire Hazard
Penalty
Summary
A deficiency was identified when surveyors observed a hydrocollator machine, used for hot pads, placed on top of a towel in the therapy area. The machine was found to be hot enough to cause a heat burn upon contact, and it was not installed in a manner that would prevent combustible materials from being ignited, as required by code 19.5.2.2. The observation was confirmed by the facility Maintenance Director at the time of the survey. This situation could potentially affect eight occupants within the therapy area if ordinary combustibles come into contact with the heat source.
Plan Of Correction
Hydrocollator was removed from the shelf and towel location and installed on a metal shelf. All other heat producing equipment has been reviewed to ensure that combustible items are not touching them. Department Managers and Maintenance staff will be inserviced on the safe use of heat producing equipment. The Maintenance Director will monitor compliance by conducting rounds weekly, observing for combustible materials are keep away from heat producing equipment.
Failure to Hold Quarterly QAA Meetings
Penalty
Summary
The facility failed to ensure that Quality Assessment and Assurance (QAA) meetings were held at least quarterly, as required. During an interview, the Director of Nursing (DON) presented a QAA binder with meeting sign-in sheets and notes dated February, March, and April 2024, indicating that the facility had changed QAA meetings from quarterly to monthly starting in February 2024. However, the DON was unable to locate the quarterly sign-in sheets from September 2023 to January 2024 to confirm whether QAA meetings were held during that period and who attended. Additionally, the Assistant Director of Nursing (ADON) mentioned that a QAA meeting scheduled for November 2023 was canceled and was unsure if it was rescheduled. The facility's QAPI policy requires QAA meetings to be held at least quarterly, but there was no documentation to verify compliance with this requirement for the specified period.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure proper infection control protocols and practices, including Enhanced Barrier Precautions (EBP) and transmission-based precautions, for several residents. For instance, Resident #31, who had a suprapubic catheter, did not have any EBP signage or personal protective equipment (PPE) available for staff. Similarly, Resident #50, who had a Foley catheter, also lacked EBP signage and PPE. Resident #27, with a pressure ulcer and a Foley catheter, did not have EBP signage, and staff did not don PPE before performing wound care. Additionally, Resident #261, who had a urinary tract infection with a multidrug-resistant organism, did not have contact precautions in place, and staff entered the room without PPE. Resident #262, with multiple wounds and cellulitis, and Resident #5, with pressure ulcers, also lacked EBP signage and PPE in their rooms. The Infection Preventionist (IFP) was unaware of the updated guidance for implementing EBP for residents with wounds, pressure ulcers, and indwelling devices. The facility also failed to ensure adequate hand hygiene and hygienic wound care. For example, CNA F did not clean the Hoyer lift after transferring Resident #5, and CNA E did not perform hand hygiene after handling soiled linen and taking a drink from a personal beverage cup in the spa room. Additionally, Wound Nurse Z did not turn off a pedestal fan blowing air directly at Resident #5's feet during a dressing change, which disturbed the dressing supplies. These deficiencies resulted in an increased potential for the spread of infection, bacterial harborage, cross-contamination, and disease transmission among residents. The facility's failure to implement proper infection control measures, including EBP and hand hygiene, compromised the safety and well-being of the residents.
Failure to Offer Updated Pneumococcal Vaccines
Penalty
Summary
The facility failed to offer the pneumococcal vaccine to four residents, resulting in a delay in the residents being given the opportunity to receive or decline the vaccination. Resident #26, a female with diagnoses including heart failure, diabetes, and dementia, had previously received PCV13 and PPSV23 but was not offered the updated PCV15 or PCV20 vaccine. The Infection Preventionist (IFP) was unaware of the changes to the immunization requirements. Similarly, Resident #50, a male with conditions such as acute kidney failure and diabetes, had also received PCV13 and PPSV23 but was not offered the updated vaccines. The IFP confirmed that this resident should have been offered the PCV15 or PCV20 vaccine as well. Resident #38, a female with dementia and Parkinson's disease, had received a pneumococcal vaccine at an unknown outside setting and should have been offered the updated vaccines according to the IFP. Resident #24, a female with diagnoses including diabetes and leukemia, had also received a vaccine from an outside provider, but this was not documented in the medical record. The IFP reported that this resident should have been offered the PCV15 or PCV20 vaccine and then PPSV23 one year later. The CDC guidelines indicate that adults who have previously received PCV13 and PPSV23 should receive a dose of PCV20 at least five years after the last pneumococcal vaccine dose, or if their vaccination history is unknown, they should receive one dose of PCV15 or PCV20.
Failure to Preserve Resident Dignity During Meal Service
Penalty
Summary
The facility failed to preserve resident dignity during meal service in the dining room for three residents who required assistance with eating. Observations revealed that these residents were seated with drinks and desserts in front of them but were unable to consume them without assistance. They were left waiting for up to 40 minutes while other residents around them were served and consumed their meals. This resulted in the residents being unable to eat or drink independently for an extended period, which could lead to feelings of embarrassment and shame. Interviews with staff members indicated that the dining room service process involved serving hall trays first, followed by residents needing some assistance, then independent residents, and finally those requiring full assistance. This process led to the residents who needed direct assistance being served last, causing them to watch their tablemates eat while they waited. The Director of Nursing and Assistant Director of Nursing acknowledged that residents should not be left waiting to be served while others at their table are eating, indicating a recognition of the issue but no immediate corrective action was mentioned in the report.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to provide a written notice of transfer for a resident who was hospitalized, resulting in the potential for residents and/or their representatives being uninformed of the reason for transfer and their rights. The resident, who had a Brief Interview for Mental Status (BIMS) score indicating intact cognition, was discharged to the hospital due to a myocardial infarction and returned to the facility after a week. During an interview, the resident could not recall receiving a written transfer notice. A review of the resident's chart and the December 2023 Transfer Log confirmed that no written notice of transfer was provided, which should have included specific information such as the reason for transfer, effective date, location, appeal rights, and contact information for relevant advocacy agencies. Interviews with facility staff, including a Registered Nurse, the Director of Nursing, and a Financial Assistant, revealed a lack of awareness and adherence to the policy requiring a transfer notice. The Director of Nursing presented paperwork sent with residents to the hospital, which did not include a transfer/discharge notice. The Financial Assistant admitted that transfer/discharge notices had not been given to residents or their responsible parties for a long time, especially if the resident wanted to go to the hospital. The facility's Discharge Planning Policy indicated that the Business Office should provide notice of transfer or discharge within 24 hours or as soon as practicable in emergency situations, but this was not followed in the case of the resident in question.
Failure to Complete Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist completed a monthly medication regimen review for one resident reviewed for unnecessary medication use. Resident #28, who had diagnoses including vascular dementia, insomnia, and chronic pain, was mildly cognitively impaired with a BIMS score of 11 out of 15. The resident had a physician's order for lorazepam to be taken as needed up to four times a day. Despite the care plan indicating the need for pharmacy consultant reviews, no monthly medication regimen reviews were found in the resident's medical record from January 2024 to April 2024. This was confirmed by the Director of Nursing, who reported that no reviews had been completed during this period.
Failure to Limit PRN Psychotropic Medication and Implement GDRs
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medication use, specifically in the case of Resident #28. Resident #28, who had diagnoses including vascular dementia, insomnia, and chronic pain, was prescribed lorazepam 0.5 mg PRN for anxiety with no end date. The care plan indicated that the resident should be prescribed the lowest effective dose and that the resident's mood and response to the medication should be observed. However, the PRN order for lorazepam was not limited to 14 days as required for psychotropic medications, and no gradual dose reductions (GDRs) were attempted for the resident's PRN use of lorazepam. Interviews with the RN and DON confirmed that the PRN order was open-ended and that no GDRs had been completed for Resident #28. The Director of Nursing (DON) reported that new medication orders were reviewed by the clinical team in daily meetings and all medications were reviewed weekly, but no audits were completed on original orders. This lack of auditing and failure to implement GDRs or limit the PRN order to 14 days resulted in incomplete monitoring of the use, potential adverse reactions, and dosage adjustments of the psychotropic medication for Resident #28.
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Illustrative
What surveyors actually found near you
We read the 142 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Sturgis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fairview Nursing And Rehabilitation Community | 10.4 mi | ★★★★★ | 1 | 0 |
| Life Care Center Of Lagrange | 10.4 mi | ★★★★★ | 4 | 0 |
| Waters Of Lagrange Skilled Nursing Facility, The | 10.7 mi | ★★★★★ | 10 | 0 |
| Optalis Health And Rehabilitation Of Three Rivers | 15.5 mi | ★★★★★ | 41 | 0 |
| The Orchards At Three Rivers | 17.8 mi | ★★★★★ | 49 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.